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Based on record review, observation, and interview, the facility failed to maintain the fire-rated separation in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.1.3, 19.1.3.3, 7.2.1.8, 8.3, 8.3.1, 8.3.1.2, 8.3.3, 8.3.3.1, & 8.3.5. This deficient practice has the potential to affect an isolated number of patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 12/14/2021 at 1:47 pm, observation revealed that the 3-hour fire-rated door separating the Hospital from the Main Clinic did not positively latch, as the electric strike plate was not in locked status, kept in the open position. Staff C stated that the facility keeps the door in unlocked status during business hours. Staffs C and FF both stated that they don't think the electric strike plates are connected to the fire alarm system.

2. On 12/15/2021 at 2:50 pm, record review of the annual fire alarm testing report, by LVC Co. on 8/9/21, revealed that electric strike plate locking in the 3-hour fire-rated door separating the Hospital from the Main Clinic was not included in the annual testing.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on observation and interview, the facility did not ensure that the stair shaft is maintained in accordance with NFPA 101 (2012 edition) Sections 19.2.2.3, 7.1.3.2.3, and 7.2.2.5.3. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

On 12/15/2021 at 11:21 am, observation revealed that the lower landing of the S100 Stairwell was being used for storage of four (4) wheeled carts, a desk, a chair, and miscellaneous supplies.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.











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Based on observation and interview, the facility did not ensure that the stair shaft is maintained in accordance with NFPA 101 (2012 edition) Sections 39.2.2.3, 7.1.3.2.3, and 7.2.2.5.3. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

On 12/15/2021 at 11:14 am, observation at the Unity Clinic revealed that the lower landing of the interior Stairwell at the rear of the building was being used for storage of a dust pan, a 3 foot push broom, one snow shovel, and a wood door slab.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff FF.

Based on observation and staff interview, the facility did not ensure that emergency illumination equipment was provided in the event of utility power failure in accordance per the requirements of NFPA 101 (2012 edition) Sections 19.2.9.1, 7.9.1.1, 7.9.1.2, 7.9.2.1, and 7.9.2.3. This deficient practice could affect all patients, staff, and visitors.

Findings include:

1. On 12/14/2021 at 11:55 am, observation revealed discharge lighting outside of the West View Lounge Exit that was not equipped with battery backup power. Staff A confirmed that discharge lighting provided at exits are not on battery backup power. Surveyor asked if the exit discharge lighting was powered by the generator and both Facilities Director C and Maintenance Manager FF responded, "I don't know." Facilities Director C stated "we will have to ask our electrician."

2. On 12/14/2021 at 2:01 pm, observation revealed discharge lighting was not provided outside of the MRI Exit.

3. On 12/14/2021 at 3:35 pm, observation revealed discharge lighting was not provided outside of the OB South Exit.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on observation and interview, the facility did not mark the exit access in accordance NFPA 101 (2012 edition) Sections 19.2.10, 7.10.1.2, 7.10.1.5, 7.10.5.1. This deficiency had the potential to affect all patients, staff, and visitors.

Findings include:

On 12/14/2021 at 3:09 pm, observation revealed that the door leading from the Emergency Department (ED) into the Main Lobby was marked by an "exit" sticker placed on ED side of the door. There was no illuminated exit sign installed at the exit access door.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on record review, observation, and interview, the facility failed to provide protection of vertical openings and shafts with self-closing doors in accordance with NFPA 101 (2012 edition) Sections 19.3.1, 7.2.1.8, 8.6, & 8.3.4. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 12/14/2021 at 11:57 am, observation revealed that the 2nd floor door to the Med Surge North Stairwell did not positively latch. The 90-minute fire-rated door was equipped with an automatic closer.

2. On 12/14/2021 at 12:33 pm, observation revealed that the first floor door to the Med Surge South Stairwell did not positively latch, as the latching mechanism had been removed from the door. The 90-minute fire-rated door was equipped with an automatic closer.

3. On 12/14/2021 at 12:35 pm, observation revealed that the 2nd floor door to the Med Surge South Stairwell did not positively latch as the electric strike plate was kept in the open position. Facilities Director C stated that the facility keeps the door in unlocked status during business hours. Staffs C and FF both stated that they don't think the electric strike plates are connected to the fire alarm system.

4. On 12/15/2021 at 2:50 pm, record review of the annual fire alarm testing report, by LVC Co. on 8/9/21, revealed that electric strike plate locking in the 2nd floor door to the Med Surge South Stairwell was not included in the annual testing. The Pre/Post Operative Suite contained treatment and examination rooms.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on observation and interview, the facility failed to protect hazardous areas in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.1, 19.3.2.1.2, 19.3.2.1.3, 19.3.2.1.5, 19.3.6.3.5(1), 19.3.6.3.11. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 12/14/2021 at 1:56 pm, observation in ED Storage revealed a storage room used for the storage of combustible supplies. The door was not equipped with a self-closer or automatic closing hardware.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

2. On 12/15/2021 at 10:54 am, observation revealed that the double doors to Mechanical Room L121 did not fully close as the doors were being held open by the door coordinator.

3. On 12/15/2021 at 10:57 am, observation in the Mechanical Room L121 revealed a 2'x4' hole in the 1-hour fire-rated barrier, with two (2) water lines passing through.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observation and interview, the facility did not install smoke detectors in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4, and 9.6; NFPA 72 (2010 edition) Sections 17.7.4, 17.7.5.3.3, 17.7.5.6.5.1. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 12/14/2021 at 12:10 pm, observation at the smoke barrier doors, next to Room 205, revealed that the nearest smoke detector was located 16-feet away from the doors. The doors were held open by electromagnetic hold open devices that were tied into the fire alarm system.

2. On 12/15/2021 at 8:28 am, observation in the Decontamination Room revealed that a smoke detector was installed 1-foot away from an air supply diffuser, subject to airflow.

3. On 12/15/2021 at 8:30 am, observation in Utility 2 revealed that a smoke detector was installed 1-foot away from an air supply diffuser, subject to airflow.

4. On 12/15/2021 at 8:49 am, observation in the surgical corridor, outside of the Autoclave Room, revealed that a smoke detector was installed 1-foot away from an air supply diffuser, subject to airflow.

5. On 12/15/2021 at 10:14 am, observation in the Main IT Work Room revealed that a smoke detector was installed 2-feet away from an air supply diffuser, subject to airflow.

6. On 12/15/2021 at 10:15 am, observation at the smoke barrier doors, near the Basement IT Room, revealed that the nearest smoke detector was located 15-feet away from the doors. The doors were held open by electromagnetic hold open devices that were tied into the fire alarm system.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff C.

Based on record review and interview, the facility did not perform testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4 and 9.6.1.3 and NFPA 72 (2010 edition) Sections 14.3.1 and 14.4.5. This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 12/15/2021 at 2:45 pm, review of fire alarm inspection and testing documents revealed that the semi-annual visual inspection of alarm initiating devices for smoke detectors, heat detectors, duct detectors, electromechanical releasing devices (door hold opens), and manual fire alarm boxes (pull stations) was conducted once, on 8/9/2021, by LVC Co. within the last year.

2. On 12/15/2021 at 2:54 pm, review of fire alarm inspection and testing documents over the past 36 months revealed that the facility could not provide documentation of sensitivity testing. Surveyor asked when the last sensitivity testing was performed and Maintenance Manager FF stated, "I can't attest that they've done one since I've been here." Maintenance Manager FF has worked at the facility for approximately 5-years.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on observation and staff interview, the facility failed to fully sprinkler protect the building in accordance with NFPA 101 (2012 edition) Sections 19.3.5.3, 19.1.6, 19.3.5, 9.7.1.1; NFPA 13 (2010 edition) Sections 8.1, 8.6.7(4), 8.7, 8.15.3.2.1, 8.15.7. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 12/14/2021 at 11:30 am, observation in the Med Surge North Stairwell revealed that the exit stairwell was not sprinkler protected at the top of the shaft and under the first accessible landing above the bottom of the shaft. The stairwell served all four floors, including the Helipad.

2. On 12/14/2021 at 12:30 pm, observation in the Med Surge South Stairwell revealed that the exit stairwell was not sprinkler protected at the top of the shaft and under the first accessible landing above the bottom of the shaft. The stairwell served all four floors, including the Helipad.

3. On 12/14/2021 at 3:45 pm, observation outside of the Main Entrance Atrium revealed the outdoor canopy projected 16-feet from the building and was supported by wooden columns and bracing. Observation revealed that the canopy was not sprinkler protected. Facilities Director C stated he did not know if the wooden support members were fire-treated.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1 & 9.7.5; NFPA 25 (2011 edition) Sections 4.3, 5.1.1.2, 5.3.1.1.1.6, 5.2.4. This deficient practice could affect all patients, staff, and visitors.

Findings include:

1. On 12/15/2021 at 2:15 pm, review of sprinkler system maintenance records revealed that the facility did not document monthly inspections of the wet sprinkler system gauges or the weekly inspections of the dry system sprinkler gauges.

2. On 12/15/2021 at 2:17 pm, review of sprinkler system inspection, testing, and maintenance reports, revealed that the facility uses both wet and a dry sprinkler systems, but was unable to confirm that dry system sprinkler heads have been tested or replaced within the past 10-years. Maintenance Manager FF stated that the dry sprinkler system was installed under the Materials Loading Canopy in 2009 and that he did not know if the dry heads had been tested or replaced within the past 10-years.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on record review, observation, and interview the facility failed to provide corridor wall separations as required in NFPA 101 (2012 edition) Sections 19.3.6, 7.2.1.8 and 19.3.6.1. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 12/14/2021 at 11:15 am, observation revealed that Main Waiting Room and Reception area were open to the exit access corridor. The space was not fully smoke detected and was not arranged or located to allow direct supervision by the facility staff from a nurses' station or similar space during all hours. Facilities Director C stated that the reception desk is staffed only during regular business hours.

2. On 12/14/2021 at 12:22 pm, observation revealed that the door to the Med Surge Therapy Room did not positively latch, as the electric strike plate was kept in the open position, making the space open to the exit access corridor. Facilities Director C stated that the facility keeps the door in unlocked status during business hours. Staffs C and FF both stated that they don't think the electric strike plates are connected to the fire alarm system.

3. On 12/15/2021 at 2:50 pm, record review of the annual fire alarm testing report, by LVC Co. on 8/9/21, revealed that electric strike plate locking in the door to the Med Surge Therapy Room was not included in the annual testing. There was no electrically supervised automatic smoke detection in the room and the space was not arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.

4. On 12/14/2021 at 2:13 pm, observation revealed a horizontal sliding windows in the corridor wall, separating the corridor from the Radiology Suite, that did not positively latch, making the space open to the corridor. The Radiology Suite contained treatment and examination rooms.

5. On 12/14/2021 at 2:20 pm, observation revealed that Radiology Waiting Room was open to the exit access corridor. The space was not fully smoke detected and was not arranged or located to allow direct supervision by the facility staff from a nurses' station or similar space during all hours. Facilities Director C stated that the Radiology reception desk is staffed only during regular business hours.

6. On 12/14/2021 at 3:51 pm, observation revealed that the door to the Pre/Post Operation Suite did not positively latch, as the electric strike plate was kept in the open position, making the space open to the exit access corridor. Facilities Director C stated that the facility keeps the door in unlocked status during business hours. Staffs C and FF both stated that they don't think the electric strike plates are connected to the fire alarm system.

7. On 12/15/2021 at 2:50 pm, record review of the annual fire alarm testing report, by LVC Co. on 8/9/21, revealed that electric strike plate locking in the door to the Pre/Post Operation Suite was not included in the annual testing. The Pre/Post Operation Suite contained treatment and examination rooms.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 edition) Sections 19.3.6.3. This deficient practice could affect an undetermined number of patients, staff, and visitors.

Findings include:

1. On 12/14/2021 at 12:13 pm, observation revealed that the corridor door to the 2nd floor Clean Supply Closet, across from Room 206, did not positively latch.

2. On 12/14/2021 at 3:31 pm, observation revealed that the corridor doors to the OB Storage Closet, next to LDRP2, did not positively latch, as the inactive leaf latched into the frame using a manual throw-bolt located on the meeting edge of the door. The double doors did not positively latch unless the throw bolt was manually engaged prior to closing the active door leaf.

3. On 12/14/2021 at 3:33 pm, observation revealed that the corridor doors to the OB Clean Linen Closet did not positively latch, as the inactive leaf latched into the frame using a manual throw-bolt located on the meeting edge of the door. The double doors did not positively latch unless the throw bolt was manually engaged prior to closing the active door leaf. The inactive leaf was not latched into the frame when the surveyor initially tested the door, as the throw bolt had not been engaged.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

4. On 12/15/2021 at 10:49 am, observation revealed that the corridor door to the Dish Room, equipped with self-closing hardware, did not fully close as the door was propped open by a dish crate. Staff C moved the crate, and the door did not fully close as dish cart blocked it from closing. Staff C moved the cart, and the door did not positively latch.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.7, 19.3.7.1, 19.3.7.3, 8.5, 8.5.2 and 8.5.6. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 12/14/2021 at 11:26 am, observation above the ceiling tiles at the 2nd Floor Smoke Barrier, by the Infusion Suite, revealed a data cable passing through a 2"x3" hole in the drywall, a 3/4" flexible conduit passing through a 2"x2" hole in the drywall, and a 1" conduit sleeve penetration that were not protected by a system or material capable of restricting the transfer of smoke.

2. On 12/14/2021 at 12:19 pm, observation revealed that the door to the 2nd Floor Equipment Storage Closet, in the smoke barrier, did not fully self-close.

3. On 12/14/2021 at 3:55 pm, observation above the ceiling at the 1st Floor Smoke Barrier, at the Staff Entrance to the Surgical Suite from the Atrium, revealed a 1/2" gap in the drywall surrounding the ductwork that was not protected by a system or material capable of restricting the transfer of smoke.

4. On 12/15/2021 at 9:01 am, observation above the ceiling tiles at the 1st Floor Smoke Barrier, at the doors separating the OB Suite from the Surgical Suite, revealed two (2) 2'x2' holes in the plaster and lath ceiling. Observation above the plaster ceiling revealed that the smoke barrier did not extend to the deck above. In addition, there were multiple 3/4" pipe penetrations in the smoke barrier wall, passing through 1-1/2" holes in the drywall that were not protected by a system or material capable of restricting the transfer of smoke.

5. On 12/15/2021 at 9:10 am, observation above the ceiling tiles at the 1st Floor Smoke Barrier, in the Surgical Suite corridor by the Autoclave Room, revealed 1/2" gap in the drywall surrounding the ductwork, and two (2) 3/4" conduit sleeve penetrations that were not protected by a system or material capable of restricting the transfer of smoke.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4, 19.7.1.6, & 19.7.1.7. This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

On 12/15/2021 at 3:54 pm, review of the facility fire drill for the last twelve months revealed that eleven (11) of the twelve (12) fire drills did not include the record of transmission of the alarm signal to the monitoring company.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on record review and interview, the facility did not inspect and test the required elements of the medical gas and vacuum systems as part of a maintenance program in accordance with the requirements of 42 CFR § 485.623(d); NFPA 99 (2012 edition) Sections 5.1.14.2.1, 5.1.14.2.2, 5.1.14.2.3, 5.2.13, 5.1.14.2.3.2. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 12/15/2021 at 2:15 pm, review of "Failure of Medical Gas Systems Procedure", dated 11/17/21, revealed that the medical gas systems are to be tested annually. On 12/15/2021 at 4:01 pm, record review of "Medical Gas Pipeline Annual Inspection" by Quintech Inc., revealed that the most recent annual inspection of the medical gas central supply was performed over 15-months ago, on 9/3/2020. Facilities Director C stated that the facility has been working on developing a contract with their medical gas inspector, but they do not have an inspection scheduled.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observation and interview, the facility failed to provide an emergency electrical generator with a remote stop in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1.1, 9.1.3.1; NFPA 99 (2012 edition) Sections 6.5.1, 6.4.1.1.16.2; NFPA 110 (2010 edition), Sections 5.6.5.6 and 5.6.5.6.1. This deficiency could affect all patients, staff, and visitors.

Findings include:

On 12/15/2021 at 11:35 am, observation revealed that the emergency generator was located outside the building by Materials Loading and that a manual stop station with a label was not provided elsewhere on the premises. Staff C confirmed that they did not know if the emergency generator, installed in 2007, was equipped with a remote emergency manual stop station.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observation and interview, the facility failed to test electrical receptacles in accordance with the requirements of NFPA 99 (2012 edition) Sections 6.3.3.2, 6.3.3.2.1, 6.3.3.2.2, 6.3.3.2.3, & 6.3.3.2.4. This deficient practice could affect all patients.

Findings include:

On 12/14/2021 at 11:35 am, observation revealed grade electrical outlets located in patient care areas. Interview with Maintenance Manager FF confirmed that the facility had no documentation of continuity of ground in circuit, polarity, or retention testing of the electrical outlets in patient care areas.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staffs C and FF.

Based on observation and interview, the facility failed to store oxygen cylinders in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.4, 8.7 and NFPA 99 (2012 edition) Sections 11.3.2.1, 11.3.2.3, 11.3.2.7, 5.1.3.3.2(6). These deficient practices could affect undetermined number of patients, staff, and visitors.

Findings include:

1. On 12/15/2021 at 10:43 am, observation in the Med Gas Room revealed a wall mounted electric heater was used for heating the space, containing six (6) nitrous oxide H-sized tanks and twelve (12) nitrogen H-sized tanks.

2. On 12/15/2021 at 11:00 am, observation in the Materials Loading Room revealed twenty (20) E-sized oxygen tanks stored less than 1-foot away from combustible styrofoam food trays, plastic garage cans, and plastic buckets.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff C.