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Based on observation and interview with staff, the facility failed to provide corridors with walls constructed with at least ? hour fire resistance rating in accordance with NFPA 101 19.3.6.1, 19.3.6.2.1, 19.3.6.5.

Findings include:

Walls above the nurses station was found to have voids and sheet rock missing.

1) Based on observation and interview staff, the facility failed to tested, and maintained fire alarm system required for life safety with applicable requirements of NFPA 70 and 72. 9.6.1.4

Findings include:

a) The annual fire alarm report provided by Tyco/Grinnell on October 1, 2013 failed to test AHU, Exhaust Fans, and Door Release.

b) Annual test failed to identify and test magnetic door locks on exterior of the building, combination fire and smoke dampers, combination fire and smoke door to zone 2 of the mental health unit(door would not close).

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

Findings include:

a) The exhaust fans located through the facility was not on a preventive maintenance program. The Director of Maintenance indicated that the conversion from the old preventive maintenance system to the new system (Facility Dude) was not transferred. Belts, motors on numerous fans were broken and not running. Patient exhaust on the Mental Health side was not working, toilet rooms grills did not have any suction.

b) Exhaust fans not working, rooms do not have outside and room air exchanges in accordance with NFPA 90 A, ASHREA Standards referenced from chapter 2.

c) Boilers installed were working, however diesel pumps and equipment required to fire the boilers off on diesel fuel was not on a preventive maintenance program. The hose used to supply pilot light for propane tank was missing. The emergency preparedness management plan could not provide continuous service in a disaster. The health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable (a)* Electricity (b) Water (c) Ventilation (d) Fire protection systems (e) Fuel sources (f) Medical gas and vacuum systems (g)* Communication systems. The fuel source was not available.

1) Based on observation and interview with staff, the facility failed to keep and maintain Means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

a) Copy machine on the Mental Health Unit is located in the egress corridor across from the nurses station.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:


a)The Medical Air Pumps were not on a preventive maintenance program

b) The Medical Air pump was not provided with a Dew Point Monitor.

c) Vacuum pumps were not on a preventive maintenance program.

1) Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) Relative humidity is not maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3

b) Shutoff valves are located outside each anesthetizing location and are arranged so that shutting off one room or location will not affect others, however staff was not trained to know location of valves. Staff was asked to demonstrate what to do if valves need shut, staff could not find valves for Operating Rooms suite. The valves were found after surveyor request; location of valves were in the sterile corridor behind supply shelves.
C-12.4.1.2.10 The facility failed to requires personnel involved in the care of patients, including nurses, aides, ward secretaries and physicians, irrespective of whether they are involved in anesthesia practices, be thoroughly indoctrinated in all aspects of fire safety, including the following
(a) The location of zone valves of nonflammable medical gas systems and the station outlets controlled by each valve
(b) The location of electrical service boxes and the areas served thereby
(c) The location and proper use of fire extinguishers (see C-12.4.4)
(d) The recommended methods and routes for evacuating patients (see Chapter 11, Health Care Emergency Preparedness)
(e) The steps involved in carrying out the fire plan of the hospital
(f) The location of fire alarm boxes, or knowledge of other methods for summoning the fire department


c) Humidity logs were provided , sample of logs indicated that many days in January & February of 2013 and in January of 2014 were less than 30% and in a lot of the days less than 20% . No corrective action was documented.

d) The humidifier in HVAC System was not working. NFPA 99 1999 edition chapter 5-6.1 requires that humidifying equipment be kept in operable condition during surgical procedures.

c) The Ventilating Equipment in HVAC System was not working. NFPA 99 1999 edition chapter 5-6.1 requires that Ventilating equipment be kept in operable condition during surgical procedures. The exhaust fan 1 belt and motor was not working. The fan was not on a preventive maintenance program.

d) Based on interview with the Operating Room staff, the unit had not conducted or made a hazard evaluation or conducted a Fire Drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel. Findings include:
(1) staff did not know what Line Isolation Monitor were.
(2) staff did not log humidity or know humidity ranges.
(3) facility could not provide documentation of training for personnel involved in the use of energy- delivering devices, including, but not limited to, electrosurgical units surgical lasers, electrocauterizers, and fiberoptics, etc. Physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel and document the findings NFPA 99 1999 edition chapter 7-6.5.

e) Perioperative Policy , Subject Administration of Anesthetic Drugs, revised 12/05/2005 stated that only non-flammable agents will be used for the preoperative preparation of the surgical field; The facility on the day of the survey had two bottles of Alcohol located in the room and alcohol was also found in the other room.

A) Based on observation and interview with staff, the facility installed doors within a required means of egress equipped with a latch or lock that requires the use of a badge,tool or key from the egress side. NFPA 101 2000 edition 19.2.2.2.4. Findings include:

5.1.7* Maintenance of Design Features. The design features required for the building to continue to meet the performance goals and objectives of this Code shall be maintained for the life of the building. Such performance goals and objectives shall include complying with all documented assumptions and design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change. 5.8.14 Use of Performance-Based Design Option. Design proposals shall include documentation that provides anyone
involved in the ownership or management of the building with notification of the following:
(1) The building was approved as a performance-based design with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.

1) The facility failed to submit and get approval for doors fitted with Magnetic locks, the locks were installed at all exterior locations of the building without an irreversible process that release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, re-locking shall be by manual means only.

2) The facility failed to get a re-acceptance testing for the fire alarm system after magnetic locks were added, in accordance with NFPA 72 chapter 7-1.6.2. Re-acceptance testing shall be provided after added or deleted components.

1) Based on observation and interview with staff, the facility failed to install and maintain within the work area of the lab, for immediate emergency use, an eyes wash for for quick drenching or flushing of the eyes in accordance with NFPA 99. 10.6 Findings include:

The eye wash was removed.

1) Based on observation and interview with staff, the facility failed to provide hypercarbic facility that comply with NFPA 99, Standard for Health Care Facilities, Chapter 19.

a) Staff member assigned the responsibilities to enforce rules and regulations with respect to practices conduct in hypercarbic facilities, including qualifications and training of hypercarbic personnel, has not been to training. Staff member who was the original agent responsible for training left the facility and is not employed .

b)The Chambers Suite located in the west end of the facility, has an Automatic Fire Suppression System installed, the system was last checked in September of 2009. The governing body failed to enforce and oversee the Responsibilities of the Hyperbaric Facility in accordance with NFPA 99 Chapter 19-3.1.3

1) Based on observation, interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2.

Findings include:

a) Line Isolation Monitor was not on a preventive maintenance program in accordance with NFPA 99 1999 edition chapter 3-3.3.4.2. The alarm in the west Operating Room would not reset. Staff had to bang on wall after about 15 minutes of alarming. Also Perioperative Policy, Subject Administration of Anesthetic Drugs, revised 12/05/2005 stated that the isolated power systems shall be tested on a monthly basis.

b) The receptacle for the Blood Bank was not marked as a Emergency Circuit. Director of Maintenance could not locate the breaker supplying power to the Blood Bank Refrigerator.

c) Electrical Panels and panel schedules were not labeled or labeled correctly, staff could not identify circuits. Single line drawing was not used or available to define panels and circuits.

d) Bio Medical Equipment and Bio Medical Rental equipment was being checked by an outside vendor. The
equipment was inspected, tested, however Individual(s) responsible for overseeing the development, implementation, and management of equipment maintenance programs was not able to demonstrate how it assures that contracted personnel, are qualified and provide quality assessment and performance improvement (QAPI) evaluation as for services provided, directly by the hospital. The rental equipment was not tested by the vendor contracted by the hospital to do electrical inspections and there was no policy that identified how to deal with rental equipment.

Based on observation and interview with staff, the facility failed to provide corridors with walls constructed with at least ? hour fire resistance rating in accordance with NFPA 101 19.3.6.1, 19.3.6.2.1, 19.3.6.5.

Findings include:

Walls above the nurses station was found to have voids and sheet rock missing.

1) Based on observation and interview staff, the facility failed to tested, and maintained fire alarm system required for life safety with applicable requirements of NFPA 70 and 72. 9.6.1.4

Findings include:

a) The annual fire alarm report provided by Tyco/Grinnell on October 1, 2013 failed to test AHU, Exhaust Fans, and Door Release.

b) Annual test failed to identify and test magnetic door locks on exterior of the building, combination fire and smoke dampers, combination fire and smoke door to zone 2 of the mental health unit(door would not close).

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

Findings include:

a) The exhaust fans located through the facility was not on a preventive maintenance program. The Director of Maintenance indicated that the conversion from the old preventive maintenance system to the new system (Facility Dude) was not transferred. Belts, motors on numerous fans were broken and not running. Patient exhaust on the Mental Health side was not working, toilet rooms grills did not have any suction.

b) Exhaust fans not working, rooms do not have outside and room air exchanges in accordance with NFPA 90 A, ASHREA Standards referenced from chapter 2.

c) Boilers installed were working, however diesel pumps and equipment required to fire the boilers off on diesel fuel was not on a preventive maintenance program. The hose used to supply pilot light for propane tank was missing. The emergency preparedness management plan could not provide continuous service in a disaster. The health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable (a)* Electricity (b) Water (c) Ventilation (d) Fire protection systems (e) Fuel sources (f) Medical gas and vacuum systems (g)* Communication systems. The fuel source was not available.

1) Based on observation and interview with staff, the facility failed to keep and maintain Means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

a) Copy machine on the Mental Health Unit is located in the egress corridor across from the nurses station.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:


a)The Medical Air Pumps were not on a preventive maintenance program

b) The Medical Air pump was not provided with a Dew Point Monitor.

c) Vacuum pumps were not on a preventive maintenance program.

1) Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) Relative humidity is not maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3

b) Shutoff valves are located outside each anesthetizing location and are arranged so that shutting off one room or location will not affect others, however staff was not trained to know location of valves. Staff was asked to demonstrate what to do if valves need shut, staff could not find valves for Operating Rooms suite. The valves were found after surveyor request; location of valves were in the sterile corridor behind supply shelves.
C-12.4.1.2.10 The facility failed to requires personnel involved in the care of patients, including nurses, aides, ward secretaries and physicians, irrespective of whether they are involved in anesthesia practices, be thoroughly indoctrinated in all aspects of fire safety, including the following
(a) The location of zone valves of nonflammable medical gas systems and the station outlets controlled by each valve
(b) The location of electrical service boxes and the areas served thereby
(c) The location and proper use of fire extinguishers (see C-12.4.4)
(d) The recommended methods and routes for evacuating patients (see Chapter 11, Health Care Emergency Preparedness)
(e) The steps involved in carrying out the fire plan of the hospital
(f) The location of fire alarm boxes, or knowledge of other methods for summoning the fire department


c) Humidity logs were provided , sample of logs indicated that many days in January & February of 2013 and in January of 2014 were less than 30% and in a lot of the days less than 20% . No corrective action was documented.

d) The humidifier in HVAC System was not working. NFPA 99 1999 edition chapter 5-6.1 requires that humidifying equipment be kept in operable condition during surgical procedures.

c) The Ventilating Equipment in HVAC System was not working. NFPA 99 1999 edition chapter 5-6.1 requires that Ventilating equipment be kept in operable condition during surgical procedures. The exhaust fan 1 belt and motor was not working. The fan was not on a preventive maintenance program.

d) Based on interview with the Operating Room staff, the unit had not conducted or made a hazard evaluation or conducted a Fire Drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel. Findings include:
(1) staff did not know what Line Isolation Monitor were.
(2) staff did not log humidity or know humidity ranges.
(3) facility could not provide documentation of training for personnel involved in the use of energy- delivering devices, including, but not limited to, electrosurgical units surgical lasers, electrocauterizers, and fiberoptics, etc. Physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel and document the findings NFPA 99 1999 edition chapter 7-6.5.

e) Perioperative Policy , Subject Administration of Anesthetic Drugs, revised 12/05/2005 stated that only non-flammable agents will be used for the preoperative preparation of the surgical field; The facility on the day of the survey had two bottles of Alcohol located in the room and alcohol was also found in the other room.

A) Based on observation and interview with staff, the facility installed doors within a required means of egress equipped with a latch or lock that requires the use of a badge,tool or key from the egress side. NFPA 101 2000 edition 19.2.2.2.4. Findings include:

5.1.7* Maintenance of Design Features. The design features required for the building to continue to meet the performance goals and objectives of this Code shall be maintained for the life of the building. Such performance goals and objectives shall include complying with all documented assumptions and design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change. 5.8.14 Use of Performance-Based Design Option. Design proposals shall include documentation that provides anyone
involved in the ownership or management of the building with notification of the following:
(1) The building was approved as a performance-based design with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.

1) The facility failed to submit and get approval for doors fitted with Magnetic locks, the locks were installed at all exterior locations of the building without an irreversible process that release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, re-locking shall be by manual means only.

2) The facility failed to get a re-acceptance testing for the fire alarm system after magnetic locks were added, in accordance with NFPA 72 chapter 7-1.6.2. Re-acceptance testing shall be provided after added or deleted components.

1) Based on observation and interview with staff, the facility failed to install and maintain within the work area of the lab, for immediate emergency use, an eyes wash for for quick drenching or flushing of the eyes in accordance with NFPA 99. 10.6 Findings include:

The eye wash was removed.

1) Based on observation and interview with staff, the facility failed to provide hypercarbic facility that comply with NFPA 99, Standard for Health Care Facilities, Chapter 19.

a) Staff member assigned the responsibilities to enforce rules and regulations with respect to practices conduct in hypercarbic facilities, including qualifications and training of hypercarbic personnel, has not been to training. Staff member who was the original agent responsible for training left the facility and is not employed .

b)The Chambers Suite located in the west end of the facility, has an Automatic Fire Suppression System installed, the system was last checked in September of 2009. The governing body failed to enforce and oversee the Responsibilities of the Hyperbaric Facility in accordance with NFPA 99 Chapter 19-3.1.3

1) Based on observation, interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2.

Findings include:

a) Line Isolation Monitor was not on a preventive maintenance program in accordance with NFPA 99 1999 edition chapter 3-3.3.4.2. The alarm in the west Operating Room would not reset. Staff had to bang on wall after about 15 minutes of alarming. Also Perioperative Policy, Subject Administration of Anesthetic Drugs, revised 12/05/2005 stated that the isolated power systems shall be tested on a monthly basis.

b) The receptacle for the Blood Bank was not marked as a Emergency Circuit. Director of Maintenance could not locate the breaker supplying power to the Blood Bank Refrigerator.

c) Electrical Panels and panel schedules were not labeled or labeled correctly, staff could not identify circuits. Single line drawing was not used or available to define panels and circuits.

d) Bio Medical Equipment and Bio Medical Rental equipment was being checked by an outside vendor. The
equipment was inspected, tested, however Individual(s) responsible for overseeing the development, implementation, and management of equipment maintenance programs was not able to demonstrate how it assures that contracted personnel, are qualified and provide quality assessment and performance improvement (QAPI) evaluation as for services provided, directly by the hospital. The rental equipment was not tested by the vendor contracted by the hospital to do electrical inspections and there was no policy that identified how to deal with rental equipment.