HospitalInspections.org

Based on observation and staff interview the facility does not assure alcohol-base hand rub dispensers are installed properly. This deficient practice would allow the alcohol-base hand sanitizer product to come into contact with ignition sources and may result in a fire, affecting approximately all patients in 1 smoke zone. The facility has a capacity of 10 and census of 1 at the time of the survey.

Findings include:

During the survey on January 2, 2019 the following is observed:

1. At 1:15 pm, it was observed that there is an alcohol based hand rub dispenser located directly above a receptacle in the anti room.

Staff M1 was present at the time of the observation and acknowledged the findings.

Review of the following NPFA standard revealed: Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:

(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA 30B, Code for the Manufacture and Storage of Aerosol Products.
(4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm).
(5) Not more than an aggregate 10 gal (37.8 L) of alcohol based hand-rub solution or 1135 oz (32.2 kg) of Level 1 aerosols, or a combination of liquids and Level I aerosols not to exceed, in total, the equivalent of 10 gal (37.8 L) or 1135 oz (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 19.3.2.6(6).
(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 19.3.2.6(5).
(7) Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source
(b) To the side of an ignition source 'within a 1 in. (25 mm) horizontal distance from the ignition source
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source
(9) Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.
(10) The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume.
(11) Operation of the dispenser shall comply with the following criteria:
(a) The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
(b) Any activation of the dispenser shall occur only when an object is placed within 4 in. (100 mm) of the sensing device.
(c) An object placed within the activation zone and left in place shall not cause more than one activation.
(d) The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.
(e) The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.
(f) The dispenser shall be tested in accordance with the manufacturer's care and use instructions each time a new refill is installed. 2012 NFPA 101, 19.3.2.6

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients in all smoke zones. The facility has a capacity of 10 and census of 1 at the time of the survey.

Findings include:

During record review on January 2, 2018, the following is revealed:

1. There is no documentation of a fire drill being conducted for the 2nd shift during the 3rd quarter.

Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 2012 NFPA 101, 19.7.1.4

Review of the following NFPA Standard revealed: Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 2012 NFPA 101, 19.7.1.6

Based on record review and staff interview the facility fails to provide for testing of the medical gas systems. This deficient practice could adversely affect approximately 8 patients using or receiving medical gases from the bulk medical gas system in one smoke zone. The facility has a capacity of 10 and census of 1 at the time of the survey.

Findings include:

On January 2, 2019 it is observed that the medical gas system has not had an annual inspection. Interview indicated that there has been no inspection and testing of this piped oxygen system or master alarms since installation in 2014.
Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: Health care facilities with installed medical
gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed. 2012 NFPA 99, 5.1.14.2.1

Review of the following NFPA Standard revealed: Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:

(1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers
2012 NFPA 99, 5.1.14.2.2.5

Review of the following NFPA Standard revealed: Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
2012 NFPA 99, 5.1.14.4.4

Review of the following NFPA Standard revealed: A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be implemented. 2012 NFPA 99, 5.1.14.4.5

Based on staff interview and document review, the facility failed to maintain and test their electrical receptacles and systems in accordance with NFPA 99. This deficient practice would affect all patients, visitors, and staff in 1 smoke zone. At the time of the survey the capacity was 10 census was 1.
Findings include:
During the survey conducted on January 2, 2019, it is revealed:
1. No documentation for any testing of the electrical receptacles.
Staff M1 was present and acknowledged finding.
NFPA Standard: NFPA 99 2012 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. 6.3.4.1 Maintenance and testing of Electrical System 6.3.4.1. 1 Where hospital-grade receptacles are required at patient bed location and in location 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. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 6.3.4.2.2 Isolated Power System (Where Installed). A permanent record shall be kept of the results of each of the tests.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all patients in 1 smoke zone. This facility has a capacity of 10 and a census of 1.

Findings include:

During the survey on January 2, 2019, the following observations were made:

1. At 1:07 pm, it was observed that there is an extension cord being used as permanent wiring in the electrical room.

Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:

(1) The receptacles are permanently attached to the equipment assembly.

(2)The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.

(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.

(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.

(5) Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. (NFPA 99) 10.2.3.6 Power strips would not be permitted for beds & chair lifts as these applications would not meet the general precautions as they could subject power strips to damage and overload. In addition, an oxygen concentrator would be considered an appliance for therapeutic purposes and therefore it would be considered line-operated medical equipment.

NFPA Standard: NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage