HospitalInspections.org

Based on observation the facility failed to provide doors suitable for keeping the door closed tightly in its frame in accordance with 19.3.6.3. Findings:

a) Door to the dinning room was not provided with latching hardware. The missing hardware was verified by Director of Engineering

b) Doors to the soiled utility/trash storage rooms located on both sides of the isolation rooms 106 and 113 are not provided with soilid core, B labeled doors and a automatic door closure.

Based on observation and interview with staff, the facility failed to maintain Smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with NFPA 101 , chapter 8.3.

a) Combination Fire and Smoke walls separating each smoke zone throughout the building were breached. The UL Rated walls were penetrated by Information and control wiring. Ceiling tiles were removed at the location of the combination fire and smoke walls, the Director of Engineering and the two IT staff members observed the walls that were breached; all three verified the condition of the walls and noted that someone busted the sheet rock to pull wire threw, thus what caused the deficient practice and damaged the continuity of the smoke walls.

Based on observation and interview with staff, the facility failed to provide One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas 19.3.2.1. Findings :

a) The two rooms constructed on both sides of the Isolation Rooms 106 and 113 were not constructed with one hour UL rated walls and doors with automatic closures. The doors were hollow core and walls did not terminate to roof structure above. Director of engineering verified the condition of the wall on December 16, 2015.

b) The nitrous oxide bottled storage room was not constructed to with one hour walls. The walls did not terminate at ceiling. Door was not provided with a closure.

Based on observation and interview with staff, and review of the fire drill reports, the facility failed to ensure that Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift in accordance with NFPA 101 19.7.1.2. Findings .

a) Based on fire drill logs the facility was only conducting drills on the day shift. Safety Officer and Director of Engineering met together in the boardroom at 4:30 pm on December 16, 2015, both verified that the facility was only conducting drills once a quarter on the day shift and not conducting any drills on the evening shift.


.

Based on observation, interview with staff and review of fire alarm report, the facility failed to maintained fire alarm equipment in accordance with NFPA 72 , chapter 19.3.4, 9.6, Findings:

a) The fire alarm report did not depict the smoke evacuation system in the operating room, combination fire and smoke dampers, control modules that control magnetic door locks. Director of Engineering and other support staff that maintain equipment, failed to sign the original report and was unable to explain the report in detail.


B) As a result of the annual fire alarm test conducted on June 17, 2015 by an outside vendor, batteries were documented as failing. Director of Engineering indicated that the batteries were replaced, however the facility failed to provide a re-acceptance test that depicts the system in compliance in accordance with NFPA 72, chapter 7.

Based on observation, interview with staff and review of records, the facility failed to provide and maintain 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:

a) The facility failed to maintain the Boiler and Tower equipment in accordance with NFPA 101, chapter 4.6.12.3.

The water tower control valve was noted as not functioning properly on a report dated February 12, 2014 from Chem-Aqua. Chem Aqua test and reports on the condition of equipment and water for the boiler, chill water, tower water and all closed water and steam systems. The report noted that the tower water was running which eliminated chemicals from protecting the tubes in the chiller. On the November report of the same year, the valve was also noted as not being repaired. Chem Aqua test reports for 2015 were not available for review, however the director of engineering stated that the tower control valve was repaired, however there was no documentation available for review..

2) Bio Medical waste and soiled utility was being stored in rooms constructed adjacent to rooms 106 and 113. The two rooms were not provided with the required exhaust fans.

3) The two isolation rooms , rooms 106 and 113 are provided with a switch to turn on the fans, and an alarm that monitors the rooms for negative air flow. Director of engineering was asked to explain the system. The director was unable to explain what the numbers on the alarm meant. There was no training documentation available to ensure that clinical staff could verify air flow and proper monitoring of equipment

4) Exhaust duct for the janitors closet east of the old ER Exam rooms was disconnected. The ceiling tiles were missing and the opening allowed the space to be open to the outside with no protection.

5) Director of engineering was asked for the filter logs that depicts the life or condition of the HEPA Filters. The director stated that he did not log the filters, he stated that filters were not provided with manometers that depicts pressure drop across filter banks.

6) Manometers were not installed to provide a method to monitor the pressure drop across the filter banks for HEPA filters located in the HVAC equipment which serves the operating rooms in accordance with ASHREA 170 chapter 6.4.

Based on observation and interview with staff,the facility failed to provide and protect Medical gas storage room in accordance with NFPA 99 4-3.1.1.2 Storage Requirements, Standards for Health Care Facilities. Findings:

a) Approximately 15 Medical Gas H cylinders were stored in the medical gas storage area, however, none of the bottles were chained to prevent from falling over.

Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, 1999 edition, chapter 12-4.1.2 Requirements for all Anesthetizing Locations Standard for Health Care Facilities. Findings:

a) The facility failed to post rules and regulations adopted by the facility in the Operating Room suite. The facility adopted a policy "Fire Safety In The OR Setting". This policy was reviewed on 11-20- 2015, however NFPA 99, chapter 12-4.1.1.4 requires the facility to post positive measures necessary for all personnel concerned with anesthetizing locations and that they are familiar with rules and regulations to ensure enforcement. Staff members were aware of the policy and procedures, however positive measure were not posted. The director of surgery stated that a fire drills were not conducted periodically with all staff including doctors in accordance with 12-4.1.2.10, Fire Loss Prevention,

Based on observation and interview with staff, the facility failed test the two Generators and exercised them under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings:

a) The existing generator logs did not provide the size of the generator and the % of load the generator was run under. The test form named Generator Run Report was not filled out completely, numerous lines / spaces on the report form were not applicable to the function of the generator.

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

a) GRI Electrical receptacles were not installed over sinks in the existing ER exam rooms.

b) Impedance ground test for patient care areas was not documented in accordance with NFPA 99, 1999 edition, chapter 3-3.3.2.1. & 3-3.3.3, Receptacle Testing in Patient Care Areas. Ground testing shall be documented until performance data indicates other wise, the facility failed to provide documented performance data gathered and presented to the governing body for review. The testing and report that was provided indicated that patient care areas met, however the report failed to document the location of receptacles, measurements + or - 10 % at frequencies of 1000 Hz or less, physical integrity of each receptacle,continuity of the grounding circuit, the correct polarity of the hot and neutral connections, and the retention force of the grounding blade, none of these indicators were documented.

c) Extension cords and electrical power strip used in Operating Room were not tested and labeled by the Bio Medical test company. The electrical power strips was not hospital grade.

d) Stryker Monitor located in the Operating Room was not tagged by the Bio Medical contractor, staff allowed the device to be used without being tested.

e) 2 Zoll Monitor Service M located in the ER were last tested in April 22 of 2015, however they were not re-tested with in the due attached to the device, the due date was October 22, 2015. The monitor was not removed from service, staff members in the OR & ER did not recognize the out of date sticker attached to the device. Staff members in OR & ER failed to adhere to establish policies and protocols adopted by the governing body for all Patient-Care-Related Electrical Appliances.

f) Dedicated emergency circuit to each patient bed location in the two recovery bays were not provided. Each bed location was provided with an emergency receptacle, however the receptacles were on the same circuit.

Based on observation the facility failed to provide doors suitable for keeping the door closed tightly in its frame in accordance with 19.3.6.3. Findings:

a) Door to the dinning room was not provided with latching hardware. The missing hardware was verified by Director of Engineering

b) Doors to the soiled utility/trash storage rooms located on both sides of the isolation rooms 106 and 113 are not provided with soilid core, B labeled doors and a automatic door closure.

Based on observation and interview with staff, the facility failed to maintain Smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with NFPA 101 , chapter 8.3.

a) Combination Fire and Smoke walls separating each smoke zone throughout the building were breached. The UL Rated walls were penetrated by Information and control wiring. Ceiling tiles were removed at the location of the combination fire and smoke walls, the Director of Engineering and the two IT staff members observed the walls that were breached; all three verified the condition of the walls and noted that someone busted the sheet rock to pull wire threw, thus what caused the deficient practice and damaged the continuity of the smoke walls.

Based on observation and interview with staff, the facility failed to provide One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas 19.3.2.1. Findings :

a) The two rooms constructed on both sides of the Isolation Rooms 106 and 113 were not constructed with one hour UL rated walls and doors with automatic closures. The doors were hollow core and walls did not terminate to roof structure above. Director of engineering verified the condition of the wall on December 16, 2015.

b) The nitrous oxide bottled storage room was not constructed to with one hour walls. The walls did not terminate at ceiling. Door was not provided with a closure.

Based on observation and interview with staff, and review of the fire drill reports, the facility failed to ensure that Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift in accordance with NFPA 101 19.7.1.2. Findings .

a) Based on fire drill logs the facility was only conducting drills on the day shift. Safety Officer and Director of Engineering met together in the boardroom at 4:30 pm on December 16, 2015, both verified that the facility was only conducting drills once a quarter on the day shift and not conducting any drills on the evening shift.


.

Based on observation, interview with staff and review of fire alarm report, the facility failed to maintained fire alarm equipment in accordance with NFPA 72 , chapter 19.3.4, 9.6, Findings:

a) The fire alarm report did not depict the smoke evacuation system in the operating room, combination fire and smoke dampers, control modules that control magnetic door locks. Director of Engineering and other support staff that maintain equipment, failed to sign the original report and was unable to explain the report in detail.


B) As a result of the annual fire alarm test conducted on June 17, 2015 by an outside vendor, batteries were documented as failing. Director of Engineering indicated that the batteries were replaced, however the facility failed to provide a re-acceptance test that depicts the system in compliance in accordance with NFPA 72, chapter 7.

Based on observation, interview with staff and review of records, the facility failed to provide and maintain 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:

a) The facility failed to maintain the Boiler and Tower equipment in accordance with NFPA 101, chapter 4.6.12.3.

The water tower control valve was noted as not functioning properly on a report dated February 12, 2014 from Chem-Aqua. Chem Aqua test and reports on the condition of equipment and water for the boiler, chill water, tower water and all closed water and steam systems. The report noted that the tower water was running which eliminated chemicals from protecting the tubes in the chiller. On the November report of the same year, the valve was also noted as not being repaired. Chem Aqua test reports for 2015 were not available for review, however the director of engineering stated that the tower control valve was repaired, however there was no documentation available for review..

2) Bio Medical waste and soiled utility was being stored in rooms constructed adjacent to rooms 106 and 113. The two rooms were not provided with the required exhaust fans.

3) The two isolation rooms , rooms 106 and 113 are provided with a switch to turn on the fans, and an alarm that monitors the rooms for negative air flow. Director of engineering was asked to explain the system. The director was unable to explain what the numbers on the alarm meant. There was no training documentation available to ensure that clinical staff could verify air flow and proper monitoring of equipment

4) Exhaust duct for the janitors closet east of the old ER Exam rooms was disconnected. The ceiling tiles were missing and the opening allowed the space to be open to the outside with no protection.

5) Director of engineering was asked for the filter logs that depicts the life or condition of the HEPA Filters. The director stated that he did not log the filters, he stated that filters were not provided with manometers that depicts pressure drop across filter banks.

6) Manometers were not installed to provide a method to monitor the pressure drop across the filter banks for HEPA filters located in the HVAC equipment which serves the operating rooms in accordance with ASHREA 170 chapter 6.4.

Based on observation and interview with staff,the facility failed to provide and protect Medical gas storage room in accordance with NFPA 99 4-3.1.1.2 Storage Requirements, Standards for Health Care Facilities. Findings:

a) Approximately 15 Medical Gas H cylinders were stored in the medical gas storage area, however, none of the bottles were chained to prevent from falling over.

Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, 1999 edition, chapter 12-4.1.2 Requirements for all Anesthetizing Locations Standard for Health Care Facilities. Findings:

a) The facility failed to post rules and regulations adopted by the facility in the Operating Room suite. The facility adopted a policy "Fire Safety In The OR Setting". This policy was reviewed on 11-20- 2015, however NFPA 99, chapter 12-4.1.1.4 requires the facility to post positive measures necessary for all personnel concerned with anesthetizing locations and that they are familiar with rules and regulations to ensure enforcement. Staff members were aware of the policy and procedures, however positive measure were not posted. The director of surgery stated that a fire drills were not conducted periodically with all staff including doctors in accordance with 12-4.1.2.10, Fire Loss Prevention,

Based on observation and interview with staff, the facility failed test the two Generators and exercised them under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings:

a) The existing generator logs did not provide the size of the generator and the % of load the generator was run under. The test form named Generator Run Report was not filled out completely, numerous lines / spaces on the report form were not applicable to the function of the generator.

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

a) GRI Electrical receptacles were not installed over sinks in the existing ER exam rooms.

b) Impedance ground test for patient care areas was not documented in accordance with NFPA 99, 1999 edition, chapter 3-3.3.2.1. & 3-3.3.3, Receptacle Testing in Patient Care Areas. Ground testing shall be documented until performance data indicates other wise, the facility failed to provide documented performance data gathered and presented to the governing body for review. The testing and report that was provided indicated that patient care areas met, however the report failed to document the location of receptacles, measurements + or - 10 % at frequencies of 1000 Hz or less, physical integrity of each receptacle,continuity of the grounding circuit, the correct polarity of the hot and neutral connections, and the retention force of the grounding blade, none of these indicators were documented.

c) Extension cords and electrical power strip used in Operating Room were not tested and labeled by the Bio Medical test company. The electrical power strips was not hospital grade.

d) Stryker Monitor located in the Operating Room was not tagged by the Bio Medical contractor, staff allowed the device to be used without being tested.

e) 2 Zoll Monitor Service M located in the ER were last tested in April 22 of 2015, however they were not re-tested with in the due attached to the device, the due date was October 22, 2015. The monitor was not removed from service, staff members in the OR & ER did not recognize the out of date sticker attached to the device. Staff members in OR & ER failed to adhere to establish policies and protocols adopted by the governing body for all Patient-Care-Related Electrical Appliances.

f) Dedicated emergency circuit to each patient bed location in the two recovery bays were not provided. Each bed location was provided with an emergency receptacle, however the receptacles were on the same circuit.