HospitalInspections.org

K211
Based on observation and staff interview, the facility does not ensure that rated fire doors are unobstructed. Failure to maintain these doors may result in delayed egress in the event of an actual emergency.

Findings include:

During the facility tour on 02/08/18 at 11:00 AM, it was observed that fire doors were obstructed. The following was observed:

-A cart containing clean supplies was obstructing fire doors in the basement area.
-Two trash cans and a cart, labeled "stork only" was blocking fire doors entering the kitchen area.

Interview with Staff (J), Facilities on 02/08/18 at 11:05 AM verified this finding.

Based on observation and interview, the facility does not ensure that the manual pull station for the Ansul is provided in the egress pathway for the fire extinguishing equipment in the kitchen Failure to provide this pull station in the egress pathway has the potential to result in harm to the staff in the event of an actual emergency.

Findings include:

Observation on 02/07/18 at 11:40 AM revealed that the pull station for the Ansul hood that is located in the kitchen was not located in the pathway of egress. This device was located on the wall, adjacent to the stainless-steel prep table, behind the grill and grease fryer. This device must be located in the pathway of egress to ensure proper activation in the event of a fire emergency.

Interview on 02/07/18 at 11:45 AM with Staff (J), Facilities verified this finding.

Based on document review and staff interview, the facility does not ensure that the number of fire alarm devices present in the facility is consistent with the number of devices tested or that sensitivity testing is performed. Failure to test all the devices may result in harm to the patients, staff and visitors in the event of an emergency.

Findings include:

Review of the Fire Alarm Test/Installation Acknowledgement reports for 2017 revealed inconsistency between the number of fire alarm components tested by the facility and the quarterly verification reports by the contracted company at the fire alarm control panel (FACP). Review of these reports indicated the following:

-Review of the 01/25/17 summary report indicates that 3 of 3 duct detectors were tested and review of the actual report does not indicate that the devices were tested, the report indicates "N/A".
-Review of the 04/25/17 summary report indicates that 36 heat detectors were tested and review of the actual report indicates that 35 heat detectors were tested; 53 smoke detectors were tested and review of the actual report indicates that 52 smoke detectors were tested; 4 duct detectors were tested and review of the actual report indicates that 7 of 13 duct detectors were tested and 6 of 13 indicates "N/A".
-Review of the 07/25/17 summary report indicates that 29 heat detectors were tested and review of the actual report indicates that 30 heat detectors were tested; 50 smoke detectors were tested and review of the actual report indicates that 51 smoke detectors were tested; duct detectors were not tested and review of the actual report indicates that 5 duct detectors were tested;
-Review of the 10/24/17 summary report indicates that 33 heat detectors were tested and review of the actual report indicates that 36 heat detectors were tested; 51 smoke detectors were tested and review of the actual report indicates that 56 smoke detectors were tested.

Review of the 2013 Fire Alarm Test/Installation Acknowledgement reports for the sensitivity testing of the smoke detectors on 02/06/18 at 1:15 PM indicates that the facility has a total of 175 smoke detection devices. Review of the 2017 fire alarm inspection reports indicates that the facility has a total of 204 smoke detectors.

Interview with Staff (J), Facilities on 02/06/17 at 1:15 PM revealed the reason for the discrepancy relative to the number of devices tested was unknown.

Based on observation and staff interview, the facility does not ensure that visual inspections are performed on the sprinkler system. Failure to perform visual inspections of the sprinkler system may result in inadequate operation of the sprinkler system in the event of an emergency.

Findings include:

During the facility tour of the dietary department on 02/07/18 at 11:00 AM, it was observed that catering supplies and dry goods were stored less that 18" from the ceiling. It was also observed that an escutcheon was lacking on the sprinkler head in the dish room.

Interview with Staff (J), Facilities and Staff (PP), Dietary on 02/07/18 at 11:30 AM verified this finding.

Based on observation and staff interview, the facility does not ensure the proper operation of the fire doors. Failure to ensure proper operation of the fire doors may result in the doors malfunctioning in the event of an actual emergency.

Findings include:

During the facility tour on 02/08/18 at 10:30 AM, it was observed that fire door 215A, entering maternity area, required repair. It was also observed that the glass in these doors was not wired and did not provide a label to verify that the glass was fire safe.

Interview with Staff (J), Facilities on 02/08/18 at 10:40 AM verified this finding.

Based on observation and staff interview, the facility does not ensure adequate protection of the smoke/fire walls. Failure to provide adequate protection of these rated walls may cause harm to the patients, staff and visitors in the event of an actual emergency.

Findings include:

During the facility tours on 02/05/18, 02/07/18 and 02/08/18, it was observed that penetrations were present in the fire/smoke rated walls. Some examples of penetrations in the rated walls were:

-On 05/05/18 at 2:45 PM in the basement, conduits that penetrated rated walls were not sealed with a fire rated material above the electrical panel LP1 and above the purchasing department door.
-On 02/07/18 at 1:30 PM on the 1st floor, penetrations were present in the 1-hour firewall of central sterile supply and a penetration (roof drain) was also present in the ceiling. It was also observed that a flammable spray foam was present in this rated wall. In the Simplex clock panel room, penetrations were present around the vacuum piping and around the hot water pipe.
-On 02/08/18 at 10:00 AM on the 2nd floor, penetrations were present above fire door 215A and in room 210.

Interview with Staff (J), Facilities verified these findings at the time of observation.

Based on document review and staff interview, the facility does not ensure that 3 of 5 backflow devices are tested annually. Failure to test these devices may result in contaminated water being present within the facility.

Findings include:

Review of the 2016 and 2017 Backflow reports on 02/08/18 at 1:30 PM revealed that the facility tests two backflow devices.

Telephone interview with Staff (J), Facilities on 02/14/18 at 3:30 PM indicated that a backflow device is present on the sprinkler system and on both boiler units.

Based on document review and staff interview, the facility does not ensure that routine maintenance is performed on 6 of 6 elevators (686, 338, 880, 590, 589, 189). Failure to performed routine maintenance on the elevators may result in failure of the elevators.

Findings include:

Review of the 2016 and 2017 elevator inspections on 02/06/18 at 12:00 PM revealed no documentation to indicate that preventative maintenance was performed quarterly on the elevators or that a "no load' test was performed annually. The following was noted:

-On elevator 686, maintenance was not performed in the 3rd quarter of 2017 and a "no load" test was not performed;
-On elevator 338, the only documented maintenance was performed on 09/22/17 and a "no load" test was not performed;
-On elevator 880, documentation was not provided to verify routine maintenance was performed during 2016 and 2017 and a "no load" test was not performed;
-On elevator 590, the only documented maintenance was the annual pressure test performed on 11/01/2017;
-On elevator 589, the only documented maintenance was the annual pressure test performed on 11/01/17;
-On elevator 189, the only documented maintenance was the annual "no load" test.

Review of maintenance policy #E-9 - Elevator Evacuation/Inspection/Safety, revised on 01/20/12 and reviewed on 01/13/15 does not indicates the frequency or what specific maintenance is to be performed quarterly or annually.

Interview with Staff (J), Facilities on 02/06/18 at 1:00 PM indicated that quarterly maintenance was required and a "no load" test was required annually.

Based on document review and staff interview, the facility does not ensure that adequate training has been provided to the staff when performing fire drills. Failure to ensure that adequate training has been provided may result in a delay in the event of an actual emergency.

Findings include:

Review of the provided documentation on 02/13/18 did not provide adequate documentation of the fire scenario, staff participation or an evaluation of the drill. This documentation must be provided to evaluate the efficiency, staff knowledge and response of the staff in the event of an actual fire emergency.

Interview with Staff (J), Facilities on 02/13/18 at 3:00 PM, indicated that the facility does have this documentation but was not provided.

Based on document review and staff interview, the facility does not ensure that the medical gas system is maintained. Failure to maintain the medical gas system may result in harm to the patients.

Findings include:

Review on 02/07/18 at 09:00 AM of the 2017 Medical Piping System Evaluation performed on 12/30/17 did not indicate that noted deficiencies had been corrected. Review of this report indicated the following:

-2 of 2 vacuum sensors were out of service and not operational in the operating room and in the cysto room;
-The zone valve for area 289-299 was leaking;
-An alarm was not provided for the oxygen, vacuum and medical air for ICU;
-A shutoff valve was not provided for the vacuum and oxygen on the 3rd floor (opposite the nurses station), for areas 201-229, areas 275-287, areas 289-299 and area of the stress test.

Interview with Staff (J), Facilities on 02/07/18 at 10:30 AM verified this finding.

Based on observation and staff interview, the facility does not ensure adequate separation of the medical gases in medical gas room #40. Failure to provide adequate separation may result in obtaining the incorrect medical gas in the event of an in an emergency.

Findings include:

During the facility tour on 02/05/18 at 2:45 PM, it was observed 7 full CO2 tanks and 3empty CO2 tanks were stored together, 3 ethelene tanks (2 full and 1 empty) labeled as " rehab" were stored in room #40 and were not secured.

Interview with Staff (J), Facilities on 02/05/18 at 2:50 PM verified this finding.

Based on document review, observation and staff interview, the facility does not ensure that ground fault circuit interrupters (GFCI) are tested semi-annually in patient care areas or that GFCI's are located in wet locations. Failure to test these outlets semi-annually may result in patient harm.

Findings include:

Review of the 2017 GFCI report on 02/08/18 at 1:15 PM revealed that the GFCI's were tested in 09/17.

During the facility tour on 02/05/18 at 3:00 PM, it was observed that a GFCI was not provided in room #36, the janitor's closet.

Interview with Staff (J), Facilities on 02/08/18 at 2:00 PM and revealed that the facility only tests the outlets annually.

Based on document review and staff interview, the facility does not ensure that 1 of 2 generators is maintained (D343). Failure to maintain the generator may result in the inadequate operation in the event of an actual emergency.

Findings include:

Review of the 2016 and 2017 Inspection and Preventive Maintenance Checklist for the emergency generator on 02/05/18 at 2:00 PM revealed that corrective actions are required for generator D343. These reports indicate that the "top tank gasket was leaking" on the Radiator/Heat Exchanger. There is no documentation to indicate this was repaired.

Interview with Staff (J), Facililities on 02/05/18 at 3:00 PM verified this finding.

Based on observation and staff interview, the facility does not ensure that 2 of 2 electrical junction boxes are maintained (rooms 243B and 252). Failure to maintain the junction boxes may result in patient, staff and visitor harm.

Findings include:

During the facility tour on 02/08/18 at 09:45 AM, it was observed that a cover was not present on the junction boxes in room 243B and room 252. These covers are required to ensure that tampering with the junction box is avoided.

Interview with Staff (J), Facilities on 02/08/18 at 10:00 AM verified this finding.