HospitalInspections.org

Based on observation, interview with staff, the facility failed to provide One hour fire/ two hour rated construction (with ? 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, and Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:
NFPA 99 1999 edition 3-4.1.1.6 + Work Space or Room for Generator.
(a) Energy converters shall be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain and resisting maximum wind velocity required by the local building code. Rooms for such equipment shall not be shared with other equipment or electrical service equipment that is not a part of the essential electrical system. [110:5-2.4]
1) The damper above the door to Emergency Generator was removed; pipe and wires are now running through the void.
2) The closure to the door for the Emergency Generator Room was removed.

Based on observation, interview with staff, and review of the Fire Drill Calendar, the facility failed to document staffs familiar with Fire Drills, conduct them unexpected times under varying conditions, and at least quarterly on each shift. The staff shall be familiar with procedures and is aware that drills are part of established routine. Findings include:

a) Facility conducted drills and had a calendar to show when drills were held, however there was no documentation of who attended or that proved staff could preform the following:
19.7.2.2 requires the facility to provide and document

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Based on observation, interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system does not have a approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

1)Facility could not provide last two years annual reports.

2)Facility last inspection was on 10- 22- 2012. Annual testing is required yearly.

Based on observation, interview with staff, and review of the Fire Suppression system, the facility failed to provide an automatic sprinkler system, it is installed in accordance with NFPA 13. The facility failed to properly maintained in Fire Suppression System accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1)The facility could not provide last two years annual test reports.

2)Facility last tested sprinkler system in August of 2012.

Based on observation, interview with staff, and review of the humidity logs, the facility failed to provide 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 include:


a) Endoscope processing is now conducted in one room. Processing of scopes SHALL be as follows: Cleaning rooms shall allow for flow of instrumentation from the contaminated area to the clean area and, finally, to storage. The clean equipment rooms, including storage, shall protect the equipment from contamination. Contaminated area shall be in a room that has an negative air flow with respect to adjacent rooms, terminal cleaning and assembly of equipment including storage shall be in a positive air flow room.

b) Current room used for Emergency Room Waiting is not in a negative air flow room in accordance with Hospital Standards Chapter 667 appendix A

c) Soiled work Room, clean work room, Operating Room Suites 1&2, sterile corridor, Endo Scope Procedure Room, etc were not documented as being negative, positive, or with proper outside and room air exchanges.

d) Isolation Room on the south end of Patient Corridor now being used as Emergency exam room has not been documented as having correct amount of air exchanges.

1) Based on observation, interview, and review of the Humidity logs, the facility failed to provide Anesthetizing locations that are protected in accordance with Standard for Health Care Facilities NFPA 99 1999 edition chapter 5.4.1.1, and NFPA 101 2000 edition chapter 19.3.2.3. Findings include:
a) Medical Gas Alarms in Maintenance Shop was not on Emergency Power or Hard Wired in.
b) automatic smoke evacuation to Operating Rooms was not installed.
c) humidifiers were not installed in the HVAC System
d) Facility failed to in-service staff and document the following requirements found in C-12.4.6 Indoctrination of Personnel ( facility did have a calendar when a drill was held, however information below or area specific information was not documented):

C-12.4.6.1 It is highly desirable that personnel involved in the care of patients, including nurses, aides, ward secretaries and physicians, irrespective of whether they are involved in anesthesia practices, be thoroughly indoctrinated in all aspects of fire safety, including the following
(a) The location of zone valves of nonflammable medical gas systems and the station outlets controlled by each valve
(b) The location of electrical service boxes and the areas served thereby
(c) The location and proper use of fire extinguishers (see C-12.4.4)
(d) The recommended methods and routes for evacuating patients (see Chapter 11, Health Care Emergency Preparedness)
(e) The steps involved in carrying out the fire plan of the hospital
(f) The location of fire alarm boxes, or knowledge of other methods for summoning the fire department

2) Based on interview with Staff C, the Operating Room staff had not conducted or made a hazard evaluation or conducted a Fire Drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel. Findings include:
(a) staff did not know what Line Isolation Monitor were.
(b) staff did not log humidity or know humidity ranges.
(c) facility could not provide documentation of training for personnel involved in the use of energy-delivering devices, including, but not limited to, electrosurgical units surgical lasers, electrocauterizers, and fiberoptics, etc. Physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel and document.

1 Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7.
(5.1.7* Maintenance of Design Features. The design features
required for the building to continue to meet the performance
goals and objectives of this Code shall be maintained for
the life of the building. Such performance goals and objectives
shall include complying with all documented assumptions and
design specifications. Any variations shall require the approval
of the authority having jurisdiction prior to the actual change.)
(See also 4.6.9.2) Findings include:
a) Nurses Station and surrounding rooms are now the emergency room suite
b) film Storage is now endo scope procedure room
c) X-Ray room is now a office
d) Labor Room is now a sleep lab
e) Precept Sleep Room is now IT Processor Room
f ) Delivery Room is now sterile storage
g) Private Patient Room 63 is now Pharmacy
h) The Emergency Room entrance is not manned.
i) Nursery is now a Trauma Room.
j) doors to corridor 16 were removed allowing cross traffic.
h) Flow in the Operating for the three designated areas, unrestricted; semi restricted; and restricted have been altered by IT, Sleep Lab, and Storage. Facility shall provide the following:
aa)The unrestricted area includes a central control point established to monitor the entrance of patients, personnel, and materials. Street clothes are permitted in this area, and traffic is not limited.
bb)The semi restricted area includes peripheral support areas of the surgical suite and has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, and corridors leading to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair.
cc)The restricted area includes operating and procedure rooms, the clean core and scrub sink areas. Surgical masks and hair coverings are required. Masks are required where open sterile supplies or scrubbed persons may be located.

2) Based on observation and interview with staff, the Governing Body failed to structure the responsibility for the elements of hospital operation,including building design, purchasing specifications, inspection procedures, maintenance schedules and training programs affecting such use. Findings include:
The facility failed provide a means and method of accountability (no required reports or a calendar of required reports to review) for Preventive Maintenance Programs including Fire Alarm Testing, Fire Suppression, Bio Medical Testing, Training of Staff, also the Governing Body allowed Spaces to be changed and modified with out approval from the authority having jurisdiction.

1) 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 include:

a) Receptacles in patient rooms are not hospital grade.

b) Receptacles changed out have not had a Impedance Ground Test NFPA 99 1999 edition chapter 3-3.3.2.1

c) Facility could not provide Impedance Test for Patient Care areas through out the hospital 3-3.4.3.1

d) There is no battery back up lighting for operating rooms.

e) Line Isolation Monitors were not on a preventive maintenance program. The audible warning lights were burnt out, the staff did not know the function of equipment.

f) No battery back up over the Transfer switch room for the Emergency Power System.

2) Based on observation, interview with staff, the facility failed to provide a program that provides an environment that is reasonably safe from the shock and burn hazards attendant with the use of electricity in patient care areas. The hospital shall establish policies and procedures related to the safe use of electric appliances. The hospital shall select a specific electrical safety program that is appropriate to its particular needs. The
physical protection afforded by the installation of an electrical distribution system that meets the requirements of NFPA 99 1999 edition and the purchase of properly constructed and tested appliances shall be augmented by having designated departments of the facility assume responsibility for the continued functioning of the electrical distribution system (Chapter 3) and the inspection, testing, and maintenance of electrical appliances (Chapter 7). The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care of patients. Findings include:

a) Facility failed to have a affective Bio Medical Program. Equipment was not tagged and staff was not familiar with Policies and Procedures.

b) Documentation of Test preformed in the past was not available upon request.

c) Equipment in need of repair or no longer used was not tagged and taken out of service.

Based on observation, interview with staff, the facility failed to provide One hour fire/ two hour rated construction (with ? 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, and Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:
NFPA 99 1999 edition 3-4.1.1.6 + Work Space or Room for Generator.
(a) Energy converters shall be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain and resisting maximum wind velocity required by the local building code. Rooms for such equipment shall not be shared with other equipment or electrical service equipment that is not a part of the essential electrical system. [110:5-2.4]
1) The damper above the door to Emergency Generator was removed; pipe and wires are now running through the void.
2) The closure to the door for the Emergency Generator Room was removed.

Based on observation, interview with staff, and review of the Fire Drill Calendar, the facility failed to document staffs familiar with Fire Drills, conduct them unexpected times under varying conditions, and at least quarterly on each shift. The staff shall be familiar with procedures and is aware that drills are part of established routine. Findings include:

a) Facility conducted drills and had a calendar to show when drills were held, however there was no documentation of who attended or that proved staff could preform the following:
19.7.2.2 requires the facility to provide and document

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Based on observation, interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system does not have a approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

1)Facility could not provide last two years annual reports.

2)Facility last inspection was on 10- 22- 2012. Annual testing is required yearly.

Based on observation, interview with staff, and review of the Fire Suppression system, the facility failed to provide an automatic sprinkler system, it is installed in accordance with NFPA 13. The facility failed to properly maintained in Fire Suppression System accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1)The facility could not provide last two years annual test reports.

2)Facility last tested sprinkler system in August of 2012.

Based on observation, interview with staff, and review of the humidity logs, the facility failed to provide 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 include:


a) Endoscope processing is now conducted in one room. Processing of scopes SHALL be as follows: Cleaning rooms shall allow for flow of instrumentation from the contaminated area to the clean area and, finally, to storage. The clean equipment rooms, including storage, shall protect the equipment from contamination. Contaminated area shall be in a room that has an negative air flow with respect to adjacent rooms, terminal cleaning and assembly of equipment including storage shall be in a positive air flow room.

b) Current room used for Emergency Room Waiting is not in a negative air flow room in accordance with Hospital Standards Chapter 667 appendix A

c) Soiled work Room, clean work room, Operating Room Suites 1&2, sterile corridor, Endo Scope Procedure Room, etc were not documented as being negative, positive, or with proper outside and room air exchanges.

d) Isolation Room on the south end of Patient Corridor now being used as Emergency exam room has not been documented as having correct amount of air exchanges.

1) Based on observation, interview, and review of the Humidity logs, the facility failed to provide Anesthetizing locations that are protected in accordance with Standard for Health Care Facilities NFPA 99 1999 edition chapter 5.4.1.1, and NFPA 101 2000 edition chapter 19.3.2.3. Findings include:
a) Medical Gas Alarms in Maintenance Shop was not on Emergency Power or Hard Wired in.
b) automatic smoke evacuation to Operating Rooms was not installed.
c) humidifiers were not installed in the HVAC System
d) Facility failed to in-service staff and document the following requirements found in C-12.4.6 Indoctrination of Personnel ( facility did have a calendar when a drill was held, however information below or area specific information was not documented):

C-12.4.6.1 It is highly desirable that personnel involved in the care of patients, including nurses, aides, ward secretaries and physicians, irrespective of whether they are involved in anesthesia practices, be thoroughly indoctrinated in all aspects of fire safety, including the following
(a) The location of zone valves of nonflammable medical gas systems and the station outlets controlled by each valve
(b) The location of electrical service boxes and the areas served thereby
(c) The location and proper use of fire extinguishers (see C-12.4.4)
(d) The recommended methods and routes for evacuating patients (see Chapter 11, Health Care Emergency Preparedness)
(e) The steps involved in carrying out the fire plan of the hospital
(f) The location of fire alarm boxes, or knowledge of other methods for summoning the fire department

2) Based on interview with Staff C, the Operating Room staff had not conducted or made a hazard evaluation or conducted a Fire Drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel. Findings include:
(a) staff did not know what Line Isolation Monitor were.
(b) staff did not log humidity or know humidity ranges.
(c) facility could not provide documentation of training for personnel involved in the use of energy-delivering devices, including, but not limited to, electrosurgical units surgical lasers, electrocauterizers, and fiberoptics, etc. Physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel and document.

1 Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7.
(5.1.7* Maintenance of Design Features. The design features
required for the building to continue to meet the performance
goals and objectives of this Code shall be maintained for
the life of the building. Such performance goals and objectives
shall include complying with all documented assumptions and
design specifications. Any variations shall require the approval
of the authority having jurisdiction prior to the actual change.)
(See also 4.6.9.2) Findings include:
a) Nurses Station and surrounding rooms are now the emergency room suite
b) film Storage is now endo scope procedure room
c) X-Ray room is now a office
d) Labor Room is now a sleep lab
e) Precept Sleep Room is now IT Processor Room
f ) Delivery Room is now sterile storage
g) Private Patient Room 63 is now Pharmacy
h) The Emergency Room entrance is not manned.
i) Nursery is now a Trauma Room.
j) doors to corridor 16 were removed allowing cross traffic.
h) Flow in the Operating for the three designated areas, unrestricted; semi restricted; and restricted have been altered by IT, Sleep Lab, and Storage. Facility shall provide the following:
aa)The unrestricted area includes a central control point established to monitor the entrance of patients, personnel, and materials. Street clothes are permitted in this area, and traffic is not limited.
bb)The semi restricted area includes peripheral support areas of the surgical suite and has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, and corridors leading to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair.
cc)The restricted area includes operating and procedure rooms, the clean core and scrub sink areas. Surgical masks and hair coverings are required. Masks are required where open sterile supplies or scrubbed persons may be located.

2) Based on observation and interview with staff, the Governing Body failed to structure the responsibility for the elements of hospital operation,including building design, purchasing specifications, inspection procedures, maintenance schedules and training programs affecting such use. Findings include:
The facility failed provide a means and method of accountability (no required reports or a calendar of required reports to review) for Preventive Maintenance Programs including Fire Alarm Testing, Fire Suppression, Bio Medical Testing, Training of Staff, also the Governing Body allowed Spaces to be changed and modified with out approval from the authority having jurisdiction.

1) 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 include:

a) Receptacles in patient rooms are not hospital grade.

b) Receptacles changed out have not had a Impedance Ground Test NFPA 99 1999 edition chapter 3-3.3.2.1

c) Facility could not provide Impedance Test for Patient Care areas through out the hospital 3-3.4.3.1

d) There is no battery back up lighting for operating rooms.

e) Line Isolation Monitors were not on a preventive maintenance program. The audible warning lights were burnt out, the staff did not know the function of equipment.

f) No battery back up over the Transfer switch room for the Emergency Power System.

2) Based on observation, interview with staff, the facility failed to provide a program that provides an environment that is reasonably safe from the shock and burn hazards attendant with the use of electricity in patient care areas. The hospital shall establish policies and procedures related to the safe use of electric appliances. The hospital shall select a specific electrical safety program that is appropriate to its particular needs. The
physical protection afforded by the installation of an electrical distribution system that meets the requirements of NFPA 99 1999 edition and the purchase of properly constructed and tested appliances shall be augmented by having designated departments of the facility assume responsibility for the continued functioning of the electrical distribution system (Chapter 3) and the inspection, testing, and maintenance of electrical appliances (Chapter 7). The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care of patients. Findings include:

a) Facility failed to have a affective Bio Medical Program. Equipment was not tagged and staff was not familiar with Policies and Procedures.

b) Documentation of Test preformed in the past was not available upon request.

c) Equipment in need of repair or no longer used was not tagged and taken out of service.