HospitalInspections.org

Based upon observation, the facility failed to maintain doors protecting corridor openings in other than required enclosures of vertical opening, exits, or hazardous areas in such condition that they will close without impediments and that the door latches.

Failure to maintain doors protecting corridor openings risks inability to contain a fire to a room and prevent the movement of the toxic products of combustion to enter patient rooms.

Findings include but are not limited to:

During a tour of the critical access hospital on 09/15/09 and 09/16/09, it was observed that:

1) Doors to the following patient rooms were obstructed by patient beds and could not be closed until the bed was moved:

Rooms 110, 117

2) The door between the exit access corridor and the acute care break room failed to close and latch

3) The door between the exit access corridor and the lab/emergency department staff lounge failed to close and latch

The hospital director of plant services confirmed the observation.

THIS IS A REPEAT DEFICIENCY.

Based on observation, the hospital failed to mark exits clearly where the way to reach an exit was not readily apparent.

Failure to clearly mark exits risks confusion in the event of an emergency requiring evacuation.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that the east-west corridor located at the north end of the surgery department had two illuminated exit signs pointing toward the east end of the corridor. The east end of the corridor ended at a door that led into the radiology department X-ray room. Another exit sign on the west side of the west door from the same corridor directed traffic into the corridor from the surgery/OB waiting room.

The hospital director of plant services stated that a remodel had removed an exit corridor where the radiology department X-ray room was now located, and that the exit now was located in the opposite direction of the way the exit signs pointed.

The exit signs pointed to a dead-end. The hospital director of plant services confirmed the observation.

Based upon observation, the facility failed to maintain the construction of a smoke barrier wall so as to provide at least a one-hour fire resistive rated construction.

Failure to maintain a smoke barrier wall risks passage of smoke from one smoke
compartment to another and could expose all patients in both compartments to toxic products of combustion.

Findings include but are not limited to:

During a tour of the critical access hospital on 11/29/2011, it was observed that the smoke barrier wall above the double smoke barrier doors near the surgery/obstetrics waiting room had an un-sealed penetration for the passage of computer wires.

THIS IS A REPEAT DEFICIENCY.

Based upon observation, the facility failed to maintain smoke barrier doors so that they will self-close and resist the passage of smoke.

Failure to maintain smoke barrier doors as required risks exposure of patients in both smoke compartments to the toxic products of combustion and smoke.

Findings include but are not limited to:

During a tour of the critical access hospital on 11/29/2011, it was observed that:

1) The smoke barrier door located between the lab corridor and the hospital waiting area failed to synchronize properly when closed. This left a gap where the two doors failed to meet and close fully.

2) The smoke barrier door located at the west end of the north corridor in the acute care unit was warped and would not close securely when shut.

The hospital facilities manager confirmed the observations.

THIS IS A REPEAT DEFICIENCY.

Based upon observation, the facility failed to maintain hazardous areas so that they are separated from other spaces by smoke resisting partitions and doors.

Failure to maintain hazard area separation risks passage of toxic products of combustion and smoke to beyond the hazardous area and into the patient care
areas.

Findings include but are not limited to:

During a tour of the critical access hospital on 11/29/2011, it was observed that:

The door to the basement Health Informatics Management room, where a large amount of combustible material was stored, failed to close and latch.

Based on observation and interview, the hospital failed to provide emergency lighting in each operating room to provide illumination automatically in the event of opening a circuit breaker or manual accidental opening of a switch controlling normal lighting, and failed to properly test emergency lighting to ensure that it is functional.

Failure to provide emergency lighting in each operating room risks patient safety during a procedure should an accidental loss of power to the lighting. Failure to test emergency lighting risks failure of the lights during a power outage.

Findings:

During a tour of the Surgery Department on 11/29/2011, it was observed that the emergency lighting was present in all three operating rooms. The emergency lighting fixtures in operating rooms #1 and #2 were tested by unplugging the devices from the wall receptacle. The resulting light was so dim that objects in the operating rooms could not be identified.

The hospital facilities manager and the operating room director both stated that there was no program to test the lights on an annual basis for 90 minutes as required by the Code.

Based on observation, the hospital failed to ensure that staff responding to fire drills follow the hospital Fire Plan to keep patient room doors closed during a fire alarm.

Failure to maintain patient room doors in a closed position during a fire emergency risks spread of smoke into the patient rooms.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that a fire drill was initiated in the obstetrics department. Surveyor #13692 observed nursing personnel shutting the patient room doors on the acute care unit, but then reopening the doors to enter the rooms for what appeared to be routine nursing tasks while the fire alarm was ringing and before the overhead page was heard announcing that the drill was completed.

The hospital policy "Fire Plan - Acute Care Units" (Effective date: 06/2000; Last approved: 11/2011) stated, in part: "The proper response to fire or smoke is R.A.C.E....Contain the fire and smoke by closing all doors in the area....Staff Duties...Close all doors, windows and file cabinets."

Based on interview and observation, the hospital failed to install a fire alarm system in accordance with the Code in a manner that would provide effective warning of fire in any part of the building, and failed to provide signage on the room containing the fire alarm control panel.

Failure to provide a complete fire alarm system risks spread of fire and smoke in the hospital before the partial fire alarm system detects the emergency.

Failure to provide signage on the room containing the fire alarm master panel risks inability of fire department personnel to quickly identify the location of the fire alarm master panel.

Findings include:

1) During an interview on 11/29/2011, the hospital facilities manager stated that a fire event occurred in the hospital basement boiler room. Smoke from this event was carried into the first floor of the hospital where patient care takes place, leading to the evacuation of patients from the acute care unit. The hospital facilities manager stated that the fire alarm system did not activate quickly during this emergency, partly because there were no smoke detectors installed in the hospital basement. This statement was confirmed during a tour of the hospital basement on the same date. It was observed that conditions in the hospital basement included potential sources of ignition, such as electrical switches and heavy electrical loads, and also included large combustible loads of patient records, as well as bottled oxygen stored in the basement.

2) During a tour of the hospital on 11/29/2011, it was observed that the fire alarm master panel was located in the basement electrical switch room. The door leading into this room did not have signage indicating that the fire alarm master panel was located in the room.

Based upon observation, the facility failed to install an automatic sprinkler system in accordance with the Code, by:

1) Failing to provide automatic fire sprinkler coverage to all areas of the building as required.
2) Failing to ensure that all sprinkler heads in a smoke compartment have the same response characteristic
3) Failure to provide signage on the sprinkler riser room.

Failure to provide required automatic fire sprinkler coverage risks increase of a fire to the size and intensity that could threaten the building.

Mixing of quick response sprinklers with standard response sprinklers risks improper sprinkler operation during a fire.

Failure to provide signage on the sprinkler riser room risks inability of fire department personnel to quickly identify the location of the sprinkler riser.

Reference: NFPA 13 5-3.1.5.2
When existing light hazard systems are converted to use quick-response sprinklers, all sprinklers in a compartment space shall be changed.

Findings include but are not limited to:

1) During a tour of the hospital on 11/29/2011, it was observed that an office in the basement used by the Health Informatics Management personnel had a suspended ceiling installed below the level of the fire sprinkler system in the basement. The sprinkler system had not been extended into the room below the suspended ceiling.

2) During a tour of the hospital on 11/29/2011, it was observed that fire sprinkler heads of both quick- and standard-response were located within one smoke compartment, in the area of the old emergency room that had been remodeled to a radiology and laboratory corridor.

3) During a tour of the hospital on 11/29/2011, it was observed that the fire sprinkler riser was located in a medical records storage room in the hospital basement. The doors leading into this room did not have signage indicating that the fire sprinkler riser was located in the room.

The hospital director of plant services confirmed the observation.

Based upon observation and record review, the facility failed to maintain the automatic sprinkler system in a reliable operating condition by failing to:

1) Ensure that required annual inspections were performed
2) Ensure that required quarterly inspections were performed
3) Ensure that nothing is attached to fire sprinkler piping
4) Ensure that fire sprinkler heads were not obstructed
5) Ensure that fire sprinkler flow switches were maintained in a secure condition
6) Ensure that fire sprinkler heads were free of dust

Failure to maintain the automatic sprinkler system in a reliable operating condition risks failure of the sprinkler system to operate in the event of a fire, and could allow the fire to grow and endanger patients, staff and visitors.

Failure to maintain storage 18 inches or more below sprinkler head deflectors risks obstruction of the spray pattern of the sprinklers, and injury to patients, staff and visitors through uncontrolled fire and smoke.

References:

NFPA 13 5-5.6 - The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

2-1 General. ...Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

[This table indicates that quarterly inspections and testing are required for these parts of the system:

Alarm devices (inspection)
Hydraulic nameplate (inspection)
Alarm devices (test)

Findings include:

1) During review of system maintenance records on 11/30/2011, it was found that there was no documentation that an annual inspection of the hospital automatic sprinkler system had been performed since 2009.

2) During review of sprinkler system maintenance records on 11/30/2011, it was found that there was no documentation of quarterly sprinkler system inspections. The hospital engineering manager stated that quarterly inspections were not performed.

3) During a tour of the hospital on 11/29/2011, it was observed that electrical conduits were attached to sprinkler system piping in the the basement boiler room and electrical switch room.

4) During a tour of the hospital on 11/29/2011, it was observed that storage on top of medical record shelving in the basement extended to within approximately 8" of the overhead sprinkler deflectors.

5) During a tour of the hospital on 11/29/2011, it was observed that the covers for two fire sprinkler flow switches were removed from the flow switches and had been removed since an inspection had been conducted according to the hospital facilities manager.

6) During a tour of the hospital on 11/29/2011, it was observed that fire sprinkler heads were coated with visible clumps of dust in the kitchen (six heads) and the obstetrics unit.

The hospital engineering manager confirmed the observations.

Based on record review and interview, the critical access hospital failed to ensure that cooking facilities were protected in accordance with 9.2.3, by:

1) Failing to inspect the fire suppression system on the kitchen grill hood at six-month intervals, and
2) Failing to clean the hood ducts of accumulated grease at a regular interval

Failure to inspect the kitchen grill hood fire suppression system risks failure of the system in the event of fire. Failure to clean accumulated grease from the kitchen hood duct system risks ignition of a fire in the ducts.

Findings include:

1) During an interview on 11/29/2011, the hospital facilities manager stated that the kitchen hood fire suppression system was not inspected on a semi-annual basis. Review of of system maintenance records on 11/30/2011 confirmed this findings.

2) During an interview on 11/29/2011, the hospital facilities manager stated that the kitchen hood duct system was not cleaned at a regular interval. The dietary manager stated that it had been about four years since the ducts had been cleaned.

A deep fat fryer was observed under the kitchen hood system. The dietary manager stated that the fryer was used approximately once every six months.

Based on observation, the hospital failed to limit the quantity of oxygen (nonflammable medical gas) stored outside of an enclosure to 300 cubic feet or less . Failure limit the amount of oxygen cylinders stored outside an enclosure puts patients, staff and visitors at risk from the effects of smoke and fire which would be accelerated in an oxygen rich environment.

[Reference:CMS Memorandum S&C-07-10, January 12, 2007; and NFPA 99 Health Care Facilities Chapter 9.4.3, 2005 Edition. Memorandum Summary: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured".]

Findings:

During a tour of the hospital on 11/29/2011, 1 "H" oxygen cylinder (244 cubic feet) and 7 "E" oxygen cylinders (approximately 175 cubic feet) were found in an area of the acute care unit that was open to the corridor.

The hospital facilities manager confirmed the observation.

Based on observation, the hospital failed to install appropriate signage on the door of the medical gas storage and supply room.

Failure to install appropriate signage on the medical gas storage and supply room risks uncertainty among emergency responders regarding the contents of the room.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that the medical gas storage and distribution room on the exterior of the south side of the hospital did not have signage indicating that oxygen was included among the medical gases stored in this room.

Based on interview and record review, the hospital failed to inspect the emergency generator on a weekly basis.

Failure to inspect the generator weekly risks unpreparedness to operate the generator under emergency conditions.

Reference:
NFPA 110 (1999)
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings include:

During a tour of the hospital on 11/29/2011, the facilities manager stated that no weekly inspections of the generator were performed. Review of generator logs on 11/30/2011 confirmed the statement.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that:

a) Two daisy-chained power cords (one power cord plugged into the other power cord) were observed in the emergency department admitting office
b) Two daisy-chained power cords were observed in the HIM office
c) An extension cord was observed in the administration office of the chief financial officer
d) Two electrical outlet covers were missing in the furnace closet in the basement office
e) A power cord was plugged into a receptacle in the furnace closet in the basement office, and extended under the door to an appliance.

The hospital facilities manager confirmed the observations.

Based on observation, the hospital failed to locate Alcohol Based Hand Rub (ABHR) dispensers in a manner where they were not installed over or adjacent to an ignition source.

Failure to keep ABHR dispensers away from ignition sources risks fire in the hospital.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that ABHR dispensors in the following locations were installed over, adjacent or within 6 inches of an ignition source:

Acute care break room
Central supply
Pharmacy
Surgery break room

The hospital facilities manager confirmed the observations.

Based upon observation, the facility failed to maintain doors protecting corridor openings in other than required enclosures of vertical opening, exits, or hazardous areas in such condition that they will close without impediments and that the door latches.

Failure to maintain doors protecting corridor openings risks inability to contain a fire to a room and prevent the movement of the toxic products of combustion to enter patient rooms.

Findings include but are not limited to:

During a tour of the critical access hospital on 09/15/09 and 09/16/09, it was observed that:

1) Doors to the following patient rooms were obstructed by patient beds and could not be closed until the bed was moved:

Rooms 110, 117

2) The door between the exit access corridor and the acute care break room failed to close and latch

3) The door between the exit access corridor and the lab/emergency department staff lounge failed to close and latch

The hospital director of plant services confirmed the observation.

THIS IS A REPEAT DEFICIENCY.

Based on observation, the hospital failed to mark exits clearly where the way to reach an exit was not readily apparent.

Failure to clearly mark exits risks confusion in the event of an emergency requiring evacuation.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that the east-west corridor located at the north end of the surgery department had two illuminated exit signs pointing toward the east end of the corridor. The east end of the corridor ended at a door that led into the radiology department X-ray room. Another exit sign on the west side of the west door from the same corridor directed traffic into the corridor from the surgery/OB waiting room.

The hospital director of plant services stated that a remodel had removed an exit corridor where the radiology department X-ray room was now located, and that the exit now was located in the opposite direction of the way the exit signs pointed.

The exit signs pointed to a dead-end. The hospital director of plant services confirmed the observation.

Based upon observation, the facility failed to maintain the construction of a smoke barrier wall so as to provide at least a one-hour fire resistive rated construction.

Failure to maintain a smoke barrier wall risks passage of smoke from one smoke
compartment to another and could expose all patients in both compartments to toxic products of combustion.

Findings include but are not limited to:

During a tour of the critical access hospital on 11/29/2011, it was observed that the smoke barrier wall above the double smoke barrier doors near the surgery/obstetrics waiting room had an un-sealed penetration for the passage of computer wires.

THIS IS A REPEAT DEFICIENCY.

Based upon observation, the facility failed to maintain smoke barrier doors so that they will self-close and resist the passage of smoke.

Failure to maintain smoke barrier doors as required risks exposure of patients in both smoke compartments to the toxic products of combustion and smoke.

Findings include but are not limited to:

During a tour of the critical access hospital on 11/29/2011, it was observed that:

1) The smoke barrier door located between the lab corridor and the hospital waiting area failed to synchronize properly when closed. This left a gap where the two doors failed to meet and close fully.

2) The smoke barrier door located at the west end of the north corridor in the acute care unit was warped and would not close securely when shut.

The hospital facilities manager confirmed the observations.

THIS IS A REPEAT DEFICIENCY.

Based upon observation, the facility failed to maintain hazardous areas so that they are separated from other spaces by smoke resisting partitions and doors.

Failure to maintain hazard area separation risks passage of toxic products of combustion and smoke to beyond the hazardous area and into the patient care
areas.

Findings include but are not limited to:

During a tour of the critical access hospital on 11/29/2011, it was observed that:

The door to the basement Health Informatics Management room, where a large amount of combustible material was stored, failed to close and latch.

Based on observation and interview, the hospital failed to provide emergency lighting in each operating room to provide illumination automatically in the event of opening a circuit breaker or manual accidental opening of a switch controlling normal lighting, and failed to properly test emergency lighting to ensure that it is functional.

Failure to provide emergency lighting in each operating room risks patient safety during a procedure should an accidental loss of power to the lighting. Failure to test emergency lighting risks failure of the lights during a power outage.

Findings:

During a tour of the Surgery Department on 11/29/2011, it was observed that the emergency lighting was present in all three operating rooms. The emergency lighting fixtures in operating rooms #1 and #2 were tested by unplugging the devices from the wall receptacle. The resulting light was so dim that objects in the operating rooms could not be identified.

The hospital facilities manager and the operating room director both stated that there was no program to test the lights on an annual basis for 90 minutes as required by the Code.

Based on observation, the hospital failed to ensure that staff responding to fire drills follow the hospital Fire Plan to keep patient room doors closed during a fire alarm.

Failure to maintain patient room doors in a closed position during a fire emergency risks spread of smoke into the patient rooms.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that a fire drill was initiated in the obstetrics department. Surveyor #13692 observed nursing personnel shutting the patient room doors on the acute care unit, but then reopening the doors to enter the rooms for what appeared to be routine nursing tasks while the fire alarm was ringing and before the overhead page was heard announcing that the drill was completed.

The hospital policy "Fire Plan - Acute Care Units" (Effective date: 06/2000; Last approved: 11/2011) stated, in part: "The proper response to fire or smoke is R.A.C.E....Contain the fire and smoke by closing all doors in the area....Staff Duties...Close all doors, windows and file cabinets."

Based on interview and observation, the hospital failed to install a fire alarm system in accordance with the Code in a manner that would provide effective warning of fire in any part of the building, and failed to provide signage on the room containing the fire alarm control panel.

Failure to provide a complete fire alarm system risks spread of fire and smoke in the hospital before the partial fire alarm system detects the emergency.

Failure to provide signage on the room containing the fire alarm master panel risks inability of fire department personnel to quickly identify the location of the fire alarm master panel.

Findings include:

1) During an interview on 11/29/2011, the hospital facilities manager stated that a fire event occurred in the hospital basement boiler room. Smoke from this event was carried into the first floor of the hospital where patient care takes place, leading to the evacuation of patients from the acute care unit. The hospital facilities manager stated that the fire alarm system did not activate quickly during this emergency, partly because there were no smoke detectors installed in the hospital basement. This statement was confirmed during a tour of the hospital basement on the same date. It was observed that conditions in the hospital basement included potential sources of ignition, such as electrical switches and heavy electrical loads, and also included large combustible loads of patient records, as well as bottled oxygen stored in the basement.

2) During a tour of the hospital on 11/29/2011, it was observed that the fire alarm master panel was located in the basement electrical switch room. The door leading into this room did not have signage indicating that the fire alarm master panel was located in the room.

Based upon observation, the facility failed to install an automatic sprinkler system in accordance with the Code, by:

1) Failing to provide automatic fire sprinkler coverage to all areas of the building as required.
2) Failing to ensure that all sprinkler heads in a smoke compartment have the same response characteristic
3) Failure to provide signage on the sprinkler riser room.

Failure to provide required automatic fire sprinkler coverage risks increase of a fire to the size and intensity that could threaten the building.

Mixing of quick response sprinklers with standard response sprinklers risks improper sprinkler operation during a fire.

Failure to provide signage on the sprinkler riser room risks inability of fire department personnel to quickly identify the location of the sprinkler riser.

Reference: NFPA 13 5-3.1.5.2
When existing light hazard systems are converted to use quick-response sprinklers, all sprinklers in a compartment space shall be changed.

Findings include but are not limited to:

1) During a tour of the hospital on 11/29/2011, it was observed that an office in the basement used by the Health Informatics Management personnel had a suspended ceiling installed below the level of the fire sprinkler system in the basement. The sprinkler system had not been extended into the room below the suspended ceiling.

2) During a tour of the hospital on 11/29/2011, it was observed that fire sprinkler heads of both quick- and standard-response were located within one smoke compartment, in the area of the old emergency room that had been remodeled to a radiology and laboratory corridor.

3) During a tour of the hospital on 11/29/2011, it was observed that the fire sprinkler riser was located in a medical records storage room in the hospital basement. The doors leading into this room did not have signage indicating that the fire sprinkler riser was located in the room.

The hospital director of plant services confirmed the observation.

Based upon observation and record review, the facility failed to maintain the automatic sprinkler system in a reliable operating condition by failing to:

1) Ensure that required annual inspections were performed
2) Ensure that required quarterly inspections were performed
3) Ensure that nothing is attached to fire sprinkler piping
4) Ensure that fire sprinkler heads were not obstructed
5) Ensure that fire sprinkler flow switches were maintained in a secure condition
6) Ensure that fire sprinkler heads were free of dust

Failure to maintain the automatic sprinkler system in a reliable operating condition risks failure of the sprinkler system to operate in the event of a fire, and could allow the fire to grow and endanger patients, staff and visitors.

Failure to maintain storage 18 inches or more below sprinkler head deflectors risks obstruction of the spray pattern of the sprinklers, and injury to patients, staff and visitors through uncontrolled fire and smoke.

References:

NFPA 13 5-5.6 - The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition

2-1 General. ...Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

[This table indicates that quarterly inspections and testing are required for these parts of the system:

Alarm devices (inspection)
Hydraulic nameplate (inspection)
Alarm devices (test)

Findings include:

1) During review of system maintenance records on 11/30/2011, it was found that there was no documentation that an annual inspection of the hospital automatic sprinkler system had been performed since 2009.

2) During review of sprinkler system maintenance records on 11/30/2011, it was found that there was no documentation of quarterly sprinkler system inspections. The hospital engineering manager stated that quarterly inspections were not performed.

3) During a tour of the hospital on 11/29/2011, it was observed that electrical conduits were attached to sprinkler system piping in the the basement boiler room and electrical switch room.

4) During a tour of the hospital on 11/29/2011, it was observed that storage on top of medical record shelving in the basement extended to within approximately 8" of the overhead sprinkler deflectors.

5) During a tour of the hospital on 11/29/2011, it was observed that the covers for two fire sprinkler flow switches were removed from the flow switches and had been removed since an inspection had been conducted according to the hospital facilities manager.

6) During a tour of the hospital on 11/29/2011, it was observed that fire sprinkler heads were coated with visible clumps of dust in the kitchen (six heads) and the obstetrics unit.

The hospital engineering manager confirmed the observations.

Based on record review and interview, the critical access hospital failed to ensure that cooking facilities were protected in accordance with 9.2.3, by:

1) Failing to inspect the fire suppression system on the kitchen grill hood at six-month intervals, and
2) Failing to clean the hood ducts of accumulated grease at a regular interval

Failure to inspect the kitchen grill hood fire suppression system risks failure of the system in the event of fire. Failure to clean accumulated grease from the kitchen hood duct system risks ignition of a fire in the ducts.

Findings include:

1) During an interview on 11/29/2011, the hospital facilities manager stated that the kitchen hood fire suppression system was not inspected on a semi-annual basis. Review of of system maintenance records on 11/30/2011 confirmed this findings.

2) During an interview on 11/29/2011, the hospital facilities manager stated that the kitchen hood duct system was not cleaned at a regular interval. The dietary manager stated that it had been about four years since the ducts had been cleaned.

A deep fat fryer was observed under the kitchen hood system. The dietary manager stated that the fryer was used approximately once every six months.

Based on observation, the hospital failed to limit the quantity of oxygen (nonflammable medical gas) stored outside of an enclosure to 300 cubic feet or less . Failure limit the amount of oxygen cylinders stored outside an enclosure puts patients, staff and visitors at risk from the effects of smoke and fire which would be accelerated in an oxygen rich environment.

[Reference:CMS Memorandum S&C-07-10, January 12, 2007; and NFPA 99 Health Care Facilities Chapter 9.4.3, 2005 Edition. Memorandum Summary: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured".]

Findings:

During a tour of the hospital on 11/29/2011, 1 "H" oxygen cylinder (244 cubic feet) and 7 "E" oxygen cylinders (approximately 175 cubic feet) were found in an area of the acute care unit that was open to the corridor.

The hospital facilities manager confirmed the observation.

Based on observation, the hospital failed to install appropriate signage on the door of the medical gas storage and supply room.

Failure to install appropriate signage on the medical gas storage and supply room risks uncertainty among emergency responders regarding the contents of the room.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that the medical gas storage and distribution room on the exterior of the south side of the hospital did not have signage indicating that oxygen was included among the medical gases stored in this room.

Based on interview and record review, the hospital failed to inspect the emergency generator on a weekly basis.

Failure to inspect the generator weekly risks unpreparedness to operate the generator under emergency conditions.

Reference:
NFPA 110 (1999)
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings include:

During a tour of the hospital on 11/29/2011, the facilities manager stated that no weekly inspections of the generator were performed. Review of generator logs on 11/30/2011 confirmed the statement.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

During a tour of the hospital on 11/29/2011, it was observed that:

a) Two daisy-chained power cords (one power cord plugged into the other power cord) were observed in the emergency department admitting office
b) Two daisy-chained power cords were observed in the HIM office
c) An extension cord was observed in the administration office of the chief financial officer
d) Two electrical outlet covers were missing in the furnace closet in the basement office
e) A power cord was plugged into a receptacle in the furnace closet in the basement office, and extended under the door to an appliance.

The hospital facilities manager confirmed the observations.