HospitalInspections.org

Based on observation the facility failed to ensure that there were no impediments to the closing of corridor doors.

Findings:

On 7/3/12 at 2:50 PM it was observed that a soiled linen cart was obstructing the closing of a patient's door on room 2002. On the same day at 3:15 PM a soiled linen cart was blocking the closure of a corridor door on patient room 4045.

Based on observation the facility failed to ensure that, exit signs were maintained in accordance with manufacturer's specifications, and were properly placed to direct occupants towards exits.

1. On 7/3/12 at 1:30 PM it was observed that the three photoluminescent, exit signs in the laboratory suite had expiration dates of 1/2008, 1/2008, and 10/2007 printed on them.

2. On 7/5/12 at 8:50 AM it was observed that one photoluminescent, exit sign in the Environmental Services structure had a 10/2007 expiration date on it.

3. On 7/5/12 at 9:55 AM it was observed that one photoluminescent, exit sign in the OR suite had a 10/2007 expiration date on it.

4. On 7/6/12 at 9:55 AM it was revealed that one exit sign in the medical surgical suite was loosely attached to the ceiling and its lights were out.

5. On 7/6/12 at 10:00 AM one exit sign in the medical surgical suite was installed in a location which indicated the wrong path to the nearest exit.

NFPA 101 (2000 ed.) 7.1.10 Means of Egress Reliability. 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to ensure that exit accesses were continuously maintained free of impediments.

Findings include:

On 7/3/12 at 8:30 AM it was observed that two computer carts and a blood pressure, measuring machine were blocking the exit access as well as obstructing access to a fire alarm, manual pull station in the Intensive Care Unit.

On 7/5/12 at 9:05 AM it was observed that a wheeled-bed was an impediment to both an exit access and a manual fire alarm pull station, near the Cath Lab. The blocked exit door had a sign on it stating, "Emergency Exit Do Not Block", the bed had a sign on it stating, "Do Not Remove Bed".

NFPA 101, 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection and tests shall be kept by the owner for inspections by the authority having jurisdiction.

This STANDARD was not met as evidenced by:

Based on staff interview and a review of maintenance records, annual 90-minute tests of battery-operated emergency lights were not being conducted.

Findings include:

On 7/3/12 the Director of Non-Clinical Operations volunteered that the battery-powered emergency lights (not connected to the essential electrical system) had not been subject to the required annual, 90-minute testing. A review of maintenance documents confirmed that there was no written documentation of such tests. Untested, light packs were observed in the Environmental Services structure (1 set) , the Main Conference Room (2 sets), and the MRI suite (3 sets).

NFPA 13 (2010 ed.), 8.3.3.2 Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3.

This STANDARD is not met as evidenced by:

Based on observations the facility failed to ensure that all sprinklers, within a compartment, would activate at the same time.

Findings include:

On 7/6/12 at 9:00 AM it was revealed that seven of approximately 30 sprinkler heads in the Emergency Department suite were of the fusible link type. The other 23 sprinkler heads within the compartment were of the red frangible bulb, quick-response type.

On the same day at 9:17 AM it was discovered that there was one standard response and one quick response sprinkler head in Exam Room 8, which met the NFPA 13 definition of a "compartment".

NFPA 25 (2008 ed.), 5.2.1.1 Sprinklers shall be inspected from the floor level annually.
5.2.1.1.3 Glass bulb sprinklers shall be replaced if the bulbs have emptied.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that glass bulb sprinklers could be annually inspected from the floor level.

Findings include:

On 7/3/12 at 2:35 PM it was observed that 15 of 17 glass bulb sprinklers had either turned to a clear color, or were empty of fluid. The remaining two frangible bulbs were green. Also, in the physicians' parking garage, 68 of 100 glass bulb sprinklers had either turned to a clear color, or were empty. The remaining 32 were green.

On the same day at 3:35 the Director of Environmental Services contacted his sprinkler servicing company, and they indicated that the installer was supposed to replace the defective sprinkler heads under warrantee. The servicer suspected that sunlight neutralized the green color in the frangible bulbs.

On 7/5/12 the Director of Environmental Services presented this Inspector with a letter from the installer, dated 6/12/201 (2012). The installer wrote, "There is the possibility that the liquid will change color when frozen but the color change does not affect the operation of the bulb."

NFPA 10 (2002 ed) 1.5.6* Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
A.1.5.6 Acceptable means of identifying the fire extinguisher locations could include arrows, lights, signs, or coding of the wall or column.
1.5.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1.5.6.)
This STANDARD was not met as evidenced by:
Based on observation, the facility failed to ensure that means were provided to indicate the location of fire extinguishers stored in cabinets, recessed into walls.
Findings include:
On 7/3/12 at 8:40 AM it was observed that two fire extinguishers were stored in cabinets recessed into the wall along the hallway leading into the Intensive Care Unit (ICU). On 7/5/12 at 8:50 AM three fire extinguishers were seen stored in cabinets recessed into the wall along the hallway leading towards the kitchen, another one near medical records and one more near the door to the electrical room. All of these cabinets were missing locator signs. On 7/5/12 at 9:00 AM it was discovered that one fire extinguisher in a recessed, wall-mounted cabinet was concealed behind an artificial tree across from the gift shop.

NFPA 10 (2002 ed) 1.5.6* Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
A.1.5.6 Acceptable means of identifying the fire extinguisher locations could include arrows, lights, signs, or coding of the wall or column.
1.5.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1.5.6.)
This STANDARD was not met as evidenced by:
Based on observation, the facility failed to ensure that means were provided to indicate the location of fire extinguishers stored in cabinets, recessed into walls.
Findings include:
On 7/5/12 at 10:30 AM, on the third floor of Building 2 it was observed that two fire extinguishers were stored in cabinets recessed into the wall. There were no locator signs near these cabinets.

Based on observation the facility failed to ensure that staff, patients, and visitors were using proper receptacles for the disposal of smoking materials in one-of-two designated smoking areas.

Findings include:

On 7/5/12 at 1:35 PM in the courtyard near ICU (a designated smoking area), it was observed that three trash cans made of combustible material were used as receptacles for discarded tobacco products. Additionally, each of these receptacles contained combustible trash including; Styrofoam cups, paper plates and napkins. There was no metal container with a self-closing lid present, into which ashtrays could be emptied.

On 7/6/12 at 10:30 AM all combustible trash receptacles in the smoking area had been removed.

NFPA 99 (2005 ed.), Chapter 9 Gas Equipment

9.7.2.3 (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that oxygen cylinders were either chained or properly supported in carts.

Findings include:

On 7/3/12 at 1:50 PM it was observed that in the vicinity of the fenced-in, bulk (cryogenic) oxygen tanks there was a cart full of "E" cylinders. On top of the 24 cylinders secured in the cart, there were an additional ten "E" cylinders lying horizontally and unrestrained.

On 7/6/12 at 10:30 AM two, freestanding "E" cylinders were found in the oxygen room in the Medical/Surgical Unit in Building 1.

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: (a) As a substitute for fixed wiring of a structure

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that additional, fixed wiring was provided in locations where the number of electrical appliances far exceeded the number of available outlets.

Findings include:

On 7/5/12 at 8:35 AM, one office in the dietary department had two power strips plugged into one duplex outlet. A total of nine electrical appliances were plugged into these two power strips.

Based on observation, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were installed neither over, nor adjacent to, ignition sources. The two, noted deficiencies affected one of ten fire zones.

Findings include:

On 7/3/12 at 8:40 AM, it was observed that two ABHR dispensers were installed directly over two electrical outlets in the Intensive Care Unit (ICU) suite.

Based on observation the facility failed to ensure that there were no impediments to the closing of corridor doors.

Findings:

On 7/3/12 at 2:50 PM it was observed that a soiled linen cart was obstructing the closing of a patient's door on room 2002. On the same day at 3:15 PM a soiled linen cart was blocking the closure of a corridor door on patient room 4045.

Based on observation the facility failed to ensure that, exit signs were maintained in accordance with manufacturer's specifications, and were properly placed to direct occupants towards exits.

1. On 7/3/12 at 1:30 PM it was observed that the three photoluminescent, exit signs in the laboratory suite had expiration dates of 1/2008, 1/2008, and 10/2007 printed on them.

2. On 7/5/12 at 8:50 AM it was observed that one photoluminescent, exit sign in the Environmental Services structure had a 10/2007 expiration date on it.

3. On 7/5/12 at 9:55 AM it was observed that one photoluminescent, exit sign in the OR suite had a 10/2007 expiration date on it.

4. On 7/6/12 at 9:55 AM it was revealed that one exit sign in the medical surgical suite was loosely attached to the ceiling and its lights were out.

5. On 7/6/12 at 10:00 AM one exit sign in the medical surgical suite was installed in a location which indicated the wrong path to the nearest exit.

NFPA 101 (2000 ed.) 7.1.10 Means of Egress Reliability. 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This STANDARD was not met as evidenced by:

Based on observation, the facility failed to ensure that exit accesses were continuously maintained free of impediments.

Findings include:

On 7/3/12 at 8:30 AM it was observed that two computer carts and a blood pressure, measuring machine were blocking the exit access as well as obstructing access to a fire alarm, manual pull station in the Intensive Care Unit.

On 7/5/12 at 9:05 AM it was observed that a wheeled-bed was an impediment to both an exit access and a manual fire alarm pull station, near the Cath Lab. The blocked exit door had a sign on it stating, "Emergency Exit Do Not Block", the bed had a sign on it stating, "Do Not Remove Bed".

NFPA 101, 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection and tests shall be kept by the owner for inspections by the authority having jurisdiction.

This STANDARD was not met as evidenced by:

Based on staff interview and a review of maintenance records, annual 90-minute tests of battery-operated emergency lights were not being conducted.

Findings include:

On 7/3/12 the Director of Non-Clinical Operations volunteered that the battery-powered emergency lights (not connected to the essential electrical system) had not been subject to the required annual, 90-minute testing. A review of maintenance documents confirmed that there was no written documentation of such tests. Untested, light packs were observed in the Environmental Services structure (1 set) , the Main Conference Room (2 sets), and the MRI suite (3 sets).

NFPA 13 (2010 ed.), 8.3.3.2 Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3.

This STANDARD is not met as evidenced by:

Based on observations the facility failed to ensure that all sprinklers, within a compartment, would activate at the same time.

Findings include:

On 7/6/12 at 9:00 AM it was revealed that seven of approximately 30 sprinkler heads in the Emergency Department suite were of the fusible link type. The other 23 sprinkler heads within the compartment were of the red frangible bulb, quick-response type.

On the same day at 9:17 AM it was discovered that there was one standard response and one quick response sprinkler head in Exam Room 8, which met the NFPA 13 definition of a "compartment".

NFPA 25 (2008 ed.), 5.2.1.1 Sprinklers shall be inspected from the floor level annually.
5.2.1.1.3 Glass bulb sprinklers shall be replaced if the bulbs have emptied.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that glass bulb sprinklers could be annually inspected from the floor level.

Findings include:

On 7/3/12 at 2:35 PM it was observed that 15 of 17 glass bulb sprinklers had either turned to a clear color, or were empty of fluid. The remaining two frangible bulbs were green. Also, in the physicians' parking garage, 68 of 100 glass bulb sprinklers had either turned to a clear color, or were empty. The remaining 32 were green.

On the same day at 3:35 the Director of Environmental Services contacted his sprinkler servicing company, and they indicated that the installer was supposed to replace the defective sprinkler heads under warrantee. The servicer suspected that sunlight neutralized the green color in the frangible bulbs.

On 7/5/12 the Director of Environmental Services presented this Inspector with a letter from the installer, dated 6/12/201 (2012). The installer wrote, "There is the possibility that the liquid will change color when frozen but the color change does not affect the operation of the bulb."

NFPA 10 (2002 ed) 1.5.6* Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
A.1.5.6 Acceptable means of identifying the fire extinguisher locations could include arrows, lights, signs, or coding of the wall or column.
1.5.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1.5.6.)
This STANDARD was not met as evidenced by:
Based on observation, the facility failed to ensure that means were provided to indicate the location of fire extinguishers stored in cabinets, recessed into walls.
Findings include:
On 7/3/12 at 8:40 AM it was observed that two fire extinguishers were stored in cabinets recessed into the wall along the hallway leading into the Intensive Care Unit (ICU). On 7/5/12 at 8:50 AM three fire extinguishers were seen stored in cabinets recessed into the wall along the hallway leading towards the kitchen, another one near medical records and one more near the door to the electrical room. All of these cabinets were missing locator signs. On 7/5/12 at 9:00 AM it was discovered that one fire extinguisher in a recessed, wall-mounted cabinet was concealed behind an artificial tree across from the gift shop.

NFPA 10 (2002 ed) 1.5.6* Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
A.1.5.6 Acceptable means of identifying the fire extinguisher locations could include arrows, lights, signs, or coding of the wall or column.
1.5.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1.5.6.)
This STANDARD was not met as evidenced by:
Based on observation, the facility failed to ensure that means were provided to indicate the location of fire extinguishers stored in cabinets, recessed into walls.
Findings include:
On 7/5/12 at 10:30 AM, on the third floor of Building 2 it was observed that two fire extinguishers were stored in cabinets recessed into the wall. There were no locator signs near these cabinets.

Based on observation the facility failed to ensure that staff, patients, and visitors were using proper receptacles for the disposal of smoking materials in one-of-two designated smoking areas.

Findings include:

On 7/5/12 at 1:35 PM in the courtyard near ICU (a designated smoking area), it was observed that three trash cans made of combustible material were used as receptacles for discarded tobacco products. Additionally, each of these receptacles contained combustible trash including; Styrofoam cups, paper plates and napkins. There was no metal container with a self-closing lid present, into which ashtrays could be emptied.

On 7/6/12 at 10:30 AM all combustible trash receptacles in the smoking area had been removed.

NFPA 99 (2005 ed.), Chapter 9 Gas Equipment

9.7.2.3 (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that oxygen cylinders were either chained or properly supported in carts.

Findings include:

On 7/3/12 at 1:50 PM it was observed that in the vicinity of the fenced-in, bulk (cryogenic) oxygen tanks there was a cart full of "E" cylinders. On top of the 24 cylinders secured in the cart, there were an additional ten "E" cylinders lying horizontally and unrestrained.

On 7/6/12 at 10:30 AM two, freestanding "E" cylinders were found in the oxygen room in the Medical/Surgical Unit in Building 1.

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: (a) As a substitute for fixed wiring of a structure

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that additional, fixed wiring was provided in locations where the number of electrical appliances far exceeded the number of available outlets.

Findings include:

On 7/5/12 at 8:35 AM, one office in the dietary department had two power strips plugged into one duplex outlet. A total of nine electrical appliances were plugged into these two power strips.