HospitalInspections.org

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Based on record review and interview the facility failed to ensure the emergency preparedness plan included evaluations for vulnerable and/or at-risk resident population in accordance with CFR 483.73(a)(3). This failed practice placed all patients served at risk for loss and/or delay in continuity of care during an emergency situation. Findings:

Record review on 3/29/22 of the facility's emergency plan, dated 7/31/21, revealed lack of an evaluation for addressing vulnerable or populations at risk.

During an interview on 3/29/22, the Emergency Preparedness Staff #1 was unable to locate or validate the facility's evaluation of vulnerable and/or at-risk populations served by the facility.

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Based on observation and interview the facility failed to ensure an emergency egress lighting system fully illuminated in accordance with NFPA 101: 7.8 as referenced by NFPA 101: 19.2.8. This failed practice placed all occupants in the mechanical room at risk for delay in egress. Findings:

An observation on 3/25/22 at 9:00 am revealed an emergency egress light (B8L) located in the mechanical room. When tested the light was notably dim and did not provide sufficient illumination.

This finding was confirmed by the Facilities Director at the time of discovery.

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Based on observation and interview the facility failed to ensure an exit sign was displayed in the emergency room corridor that provided guidance on exit egress in accordance with NFPA 101: 7.10 as referenced by NFPA 101: 19.2.10.1. This failed practice placed occupants in three out of eight smoke compartments (on the main level) at risk for delay in exit egress during an emergency. Findings:

An observation on 3/25/22 at 10:14 am revealed no exit sign located in the emergency room corridor in the director of the main nurses' station. Specifically, occupants in Corridor 135 were not provided with two marked exit egress options.

This finding was confirmed by the Facilities Director at the time of discovery.
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Based on observation and interview the facility failed to ensure the elevator machine room was protected in accordance with NFPA 101: 19.3.2. Specifically, the facility failed to ensure the fire-rated door closed in a manner to prevent the passage of smoke. This failed practice place occupants on the basement level of the facility at risk for exposure to a smoke and/or fire environment. Findings:

An observation on 3/25/22 revealed an elevator machine room located off the facility's maintenance shop. The elevator machine room had a fire-rated door assembly and when tested the door did not operate and close in a manner that prevented the passage of smoke.

This finding was confirmed by the Facilities Director at the time of discovery.

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Based on record review and interview the facility failed to ensure smoke sensitivity testing was completed in accordance with NFPA 72: 14.4.5.3.2 as referenced by NFPA 101: 9.6.1.3. This failed practice placed all occupants at risk for delayed notification of a fire emergency via the fire alarm system. Findings:

Record review on 3/24/22 of the facility's fire alarm inspection reports revealed the last smoke sensitivity test was conducted on 1/16/19.

During an interview on 3/24/22 at 4:42 pm the Facilities Director confirmed the date of the last smoke sensitivity test which exceeded the two-year interval requirement.

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Based on record review, observation and interview the facility failed to ensure:

1) two fire extinguishers were inspected at the six-year interval required by NFPA 110: 7.3 as referenced by NFPA 101: 9.7.4.1, and

2) monthly fire extinguisher checks contained the initials of the person(s) performing the inspection in accordance with NFPA 110: 7.2.4.3 as referenced by NFPA 101: 9.7.4.1.

These failed practices placed all occupants at risk for delay in fire extinguishment. Findings:

Six-Year Internal Inspection:

Record review on 3/24/22 of the facility's annual fire extinguisher inspection report, dated 3/23/21, revealed an Amerex Halotron fire extinguisher located next the "Os elevator room" was due for its six-year internal inspection. Further review revealed an Amerex Halotron fire extinguisher located next the "B100 computer" was due for its six-year internal inspection.

Observation on 3/24/22 of the two Halotron fire extinguishers confirmed the findings noted on the 3/23/21 annual fire extinguisher inspection report.

During an interview on 3/24/22 the Facilities Director confirmed the two fire extinguishers were overdue for the six-year internal inspection per NFPA 110: 7.3.

Monthly Fire Extinguisher Inspections:

Record review on 3/24/22 of the "CY 2021 FIRE EXTINGUISHER MONTHLY INSPECTIONS" for January 2022 and February 2022 revealed no initials of the person(s) performing the monthly inspections.

These findings were acknowledged by the Facilities Director at the time of discovery.

NFPA 10 (2010) 7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded.

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Based on observation and interview the facility failed to ensure:

1) electrical outlet housing was free from damage and foreign materials;

2) electrical outlets located near a water source were ground-fault- circuit interrupters (GFCIs);

3) power strips were used in a safe manner; and

4) electrical cords were used in a manner that prevented undue stress on the physical integrity of the cord wiring and housing.

The facility failed to ensure the electrical components were maintained in accordance with NFPA 70 as referenced by NFPA 101: 9.1.2. This failed practice placed all occupants at risk for electrocution and/or increased electrical fire potential. Findings:


Electrical Outlets:

Random observations on 3/25/22 revealed the following:

- Room 108 contained two electrical outlets with broken face plates;

- Corridor outside of Room 108 had one four-plug electrical outlet with notable paint over the outlet faces;

- Room 110 contained three electrical outlets with broken face plates;

- Room 111 contained one red electrical outlet with a piece of metal lodged in the ground socket of the outlet. In addition, the room had one electrical outlet with a broken face plate;

- Room 112 contained two electrical outlets with broken face plates;

- Room 113 contained one electrical outlet with a broken face plate;

- Pharmacy Office contained one electrical outlet with painted outlet faces and one electrical outlet with a broken face plate;

The Facilities Director confirmed these findings at the time of their discovery.


GFCI Rated Outlets:

Business Office had one two-plug electrical outlet and one four-plug electrical outlet less than six feet from a sink water source.

The facility's lab had a non-GFCI rated electrical outlet installed within six feet of the "clean sink" water source.

The Facilities Director confirmed these findings at the time of their discovery.


Power strip Use:

An observation staff break room on 3/25/22 at 8:30 am revealed a microwave was plugged into a power strip.

An observation of the Materials Management room on 3/25/22 at 8:53 am revealed an actively used refrigerator plugged into a power strip.

An observation of Business Office on 3/25/22 at 9:20 am revealed a power strip located next to kitchen-like appliances with standing water located on the outlet face side of the device.

The Facilities Director acknowledged these findings at the time of their discovery.


Electrical Cord Integrity:

An observation on 3/25/22 at 10:38 am revealed a power supply cord located at the long-term care nursing desk that was suspended in mid-air with the converter box hanging at the lowest point causing strain on the electrical cord.

The Facilities Director acknowledged this finding at the time of its discovery.

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Based on record review and interview the facility failed to ensure the fire plan contained a method for extinguishment of fire on night shift in accordance with NFPA 101: 19.7.2. This failed practice placed all occupants at risk for delay in fire response and extinguishment. Findings:

Record review on 3/25/22 of the facility's policy "Fire Alarm", last revision date 2/13/2020, revealed maintenance staff were to "Respond to location of the fire ...Try to control it until arrival of [local fire department]". Further review of the policy revealed maintenance staff were the only facility employees assigned to locate and contain the fire.

During an interview on 3/25/22 the Facilities Director (FD) stated the process for fire response, noted in the 2/13/20 Fire Alarm policy, had changed since last survey. When asked if maintenance staff occupy the building on the night shifts, the FD stated no maintenance staff were regularly on the campus. The FD further stated maintenance staff would have to been called in from their homes during night shift hours.

During the same interview, the FD was asked to identify within the Fire Alarm policy who would respond and contain the fire on night shift. The FD concluded the policy does not identify who would respond and contain the fire after maintenance staff left the building for the day.

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Based on record review and interview the facility failed to ensure fire drills were conducted under varied conditions in accordance with NFPA 101: 19.7.1.6. This failed practice placed all occupants at risk for delay or an effect response by facility staff during a fire-related emergency. Findings:

Record review on 10/25/22 of fire drills conducted in 2021 revealed patterns of fire drills being conducted at similar times:

- Fire drills conducted on 2/25/21 and 12/29/21 were conducted at 1:00 pm.

- Fire drills were conducted on 3/15/22 at 10:02 am, 6/18/21 at 9:39 am, and 7/21/22 at 10:13 am.

These findings were acknowledged by the Facilities Director at the time of their discover.

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Based on interview and record review the facility failed to ensure monthly generator exercises were conducted for 30 minutes in accordance with NFPA 99: 6.4.4.1.1.4 and NFPA 110 as referenced by NFPA 101: 9.1.3. This failed practice placed all occupants at risk for delay in emergency back up power. Findings:

During an interview on 3/24/22 at 5:00 pm, the Facilities Director stated that the generators hour meter continues to count during the 5-minute cool-down cycle after a generator exercise had been conducted. The FD further stated a run time of 0.5 (30 minutes) would result in a 25-minute exercise with a 5-minute cool down cycle.

Record review on 3/24/22 of the generator run logs revealed the following generator exercise time which would have included the cool-down cycle.

Generator #1 (Onan) Monthly Exercises:
4/27/21 - Reading 0.5 = 30 minutes
5/27/21 - Reading 0.5 = 30 minutes
6/27/21 - Reading 0.5 = 30 minutes
11/27/21 - Reading 0.5 = 30 minutes
12/22/21 - Reading 0.5 = 30 minutes

Generator #2 (John Deere) Monthly Exercises:
2/26/21 - Reading 0.5 = 30 minutes
6/27/21 - Reading 0.5 = 30 minutes
11/24/21 - Reading 0.5 = 30 minutes
12/22/21 - Reading 0.5 = 30 minutes

As a result - the monthly generator exercises were conducted under load for less than 30 minutes when counting the cool-down period.

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Based on observation and interview the facility failed to ensure oxygen storage cylinders were labeled to indicate and segregate empty versus full cylinders in accordance with NFPA 99: 11.6.5 as referenced by NFPA 101: 19.3.2.4. This failed practice placed all patients at risk for delay in oxygen intervention. Findings:

An observation on 3/25/22 at 8:52 am revealed an oxygen storage room, located in the receiving bay, that contained 19 H-tanks of oxygen chained in a single section against the left side wall. Further observation revealed two "empty" signs and on one "full" sign hung on the chain that was securing the 19 H-tanks. No clear delineation of empty versus full tanks was able to be observed.

During an interview at the time of discovery the Facilities Director confirmed the signs were inappropriately displayed and did not provide obvious segregation of empty versus full medical gas tanks.

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Based on record review and interview the facility failed to ensure a continuing education program was in place for staff who handle or maintain medical gasses in accordance with NFPA 99: 11.5.2.1 as referenced by NFPA 101: 19.3.2.4. This failed practice placed all patients at risk for exposure to a fire and/or smoke environment secondary to medical gases handling and storage. Findings:

Record review of facility training logs on 3/25/22 revealed the no continuing education program pertaining to the handling and maintenance of medical gases was implemented at the facility.

During an interview on 3/25/22 the Facilities Manager and Chief Nursing Officer stated there was no continuing education program in place for staff who handle and maintain medical gases.

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