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Based on observation and interview, the facility failed to provide a clear and unobstructed egress path in the main corridor. This deficient practice would have the potential to delay egress during an emergency. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Observations on 12-11-18 at 10:31 am revealed, 10 foot by 3 foot banquet tables and a drink table set up in the middle of the corridor in the main entrance area.

During an interview on 12-11-18 at 10:31 am, Maintenance Staff A confirmed the banquet table and stated the facility was providing a holiday meal for staff and immediately informed staff to move the tables.

Based on observation and interview, the facility failed to provide emergency lighting in the Endoscopy Room where deep sedation was administered. This deficient practice would not ensure lighting during an emergency. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Observations on 12-11-18 at 11:47 am revealed, no emergency lighting was provided in the Endoscopy Room.

During an interview on 12-11-18 at 11:47 am, Maintenance Staff A confirmed the lack of emergency lighting.

2012 NFPA 99, 6.3.2.2.11.1
One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.
6.3.2.2.11.2
The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.
6.3.2.2.11.3
The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.
6.3.2.2.11.4
Units shall be capable of providing lighting for 11/2 hours.
6.3.2.2.11.5
Units shall be tested monthly for 30 seconds, and annually for 30 minutes.

Based on observation and interview, the facility failed to ensure that doors to hazard areas would resist the passage of smoke. The deficient practice would allow smoke, fire and gasses to enter the room and spread. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Observations on 12-11-18 at 11:13 am revealed, the double doors to the storage room located in the Endoscopy Room failed to be smoke tight, the right door was equipped with a manual lock, which failed to be engaged within the doorframe.

During an interview on 12-11-18 at 11:13 am, Maintenance Staff A confirmed the door was not engaged within the doorframe.

Based on observation, interview and documentation review, the facility failed to use materials in accordance with the interior finish requirements. This deficient practice has the potential to allow smoke and fire to spread throughout. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Observations on 12-11-18 at 1:45 pm revealed approximately five, 3 foot by 5 foot fabric movable room dividers in the openings behind Patient Check in area.

During an interview on 12-11-18 at 1:45 pm, Maintenance Staff A confirmed the fabric room divider and stated it was used to divide the room for sound for patient privacy.

During documentation review on 12-11-18 at 3:45 pm, Administration Staff A failed to provide documentation of the flame spread rating of the fabric.

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Record review on 12-11-18 at 2:35 pm, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period.
1. The policy lacked that the fire department, facility's insurance company, owner or owners representative, authorities having jurisdiction and the monitoring company would be notified of the impairment.
2. The policy failed to list emergency impairments would include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure.

During an interview on 12-11-18 at 2:35 pm, Administration Staff A confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
NFPA 25, 2011, 15.6 Emergency Impairments
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

Based on observation and interview, the facility failed to maintain doors in smoke barriers. This deficient practice would allow smoke to spread between smoke compartments. The facility has a capacity of 18 and a census of 3 residents at the time of the survey.

Findings are:
Observation on 12-11-18 at 12:11 and 1:23 pm revealed:
1. The fire rated smoke door between "Med Surg" and ER failed to close and latch within the doorframe.
2. The smoke doors next to the ice/water machine near the Dining Room, equipped with latching device failed to close and latch within the doorframe.

During an interview on 12-11-18 at 1:23 pm, Maintenance Staff A confirmed the door equipped with latching device failed to close within the doorframe.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Record review on 12-11-18 at 2:46 pm revealed, the fire evacuation plan failed to include the evacuation of the smoke compartments and failed to assure that staff do not cross the room where the fire originates.

During an interview on 12-11-18 at 2:46 pm, Maintenance Staff A confirmed the lack of specific evacuation.

Based on observation and interview, the facility failed to provide identification for the remote manual stop switch for the emergency generator. This deficient practice could delay shutdown of the generator during a malfunction, which could cause damage to the generator resulting in loss of emergency power. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Observation on 12-11-18 at 12:20 pm revealed, the facility failed to provide identification for the remote manual shutdown switch for the generator.

During an interview on 12-11-18 at 12:20 pm, Maintenance Staff A confirmed the lack of identification remote stop for the generator.

NFPA Standard:
2010 NFPA 110, 5.6.5.6*
All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

2010 NFPA 110, 5.6.5.6.1
The remote manual stop station shall be labeled.

Based on record review and interview, the facility failed to test patient bed receptacles annually throughout the facility. This practice increased the risk of fire from a failed outlet, which would affect all occupants. The facility has a capacity of 18 and a census of 3 residents at the time of the survey.

Findings are:
Record review on 12-11-18 at 2:48 pm revealed, documentation of annual patient bed location receptacle testing was not completed.

In an interview on 12-11-18 at 2:48 pm, Maintenance Staff A confirmed the receptacle testing failed to be implemented.

NFPA Standard:
NFPA 99, 2012, 6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2
Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3
Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1
The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2
The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3
Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4
The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on record review and interview, the facility failed to have the diesel fuel tested annually for quality. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power, which would affect the emergency systems in the facility. The facility has the capacity of 18 beds with a census of 3 on the day of survey.

Findings are:
Record review of on 12-11-18 at 2:50 pm revealed, that there was no documentation that the diesel fuel for the generator was tested for quality.

During an interview on 11-28-18 at 2:50 pm, Maintenance Staff A confirmed the lack of fuel testing.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to identify full oxygen cylinders and restrain compressed gas cylinders. This deficient practice would increase the potential of choosing oxygen cylinders in an emergency that could be confused as being empty and increase the potential for the cylinders to tip over and become a projectile. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Observation on 12-11-18 at 12:15 pm and 1:31 pm revealed:
1. Five oxygen cylinders in ER supply room failed to be identified as full and appeared to be empty cylinders mixed with full.
2. 33 oxygen cylinders in the exterior oxygen storage room failed to be restrained and separated full from empty or labeled.
3. 26 large compressed gas cylinders in the exterior oxygen storage room failed to be restrained.

During an interview on 12-11-18 at 12:15 pm and 1:31 pm, Maintenance Staff A confirmed the oxygen cylinders failed to provide labeling and were not restrained.