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Based on observation and interview, the facility failed to ensure 1 of 1 battery powered emergency light was maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. This deficient practice could affect any patient, visitor or staff in Suite #102.

Findings include:

Based on observation on 04/09/19 at 12:15 p.m. during a tour of the facility with the Maintenance Coordinator, the battery operated emergency light (#EPG 8103) in the Diabetes Management and Nutrition Clinic failed to function when its respective test button was pushed five times. Based on interview at the time of the observation, the Maintenance Coordinator acknowledged the aforementioned battery operated emergency light failed to function when its respective test button was pushed, and immediately radioed in a work service order to the maintenance staff to repair the emergency light.

Based on observation and interview, the facility failed to ensure 2 of 4 battery powered emergency lights were maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. This deficient practice could affect any patient, visitor or staff in the building.

Findings include:

Based on observations on 04/10/19 at 10:00 a.m. during a tour of the facility with the Maintenance Coordinator, two battery operated emergency lights #EPG 5400 4 and #EPG5400 5 in the Memorial Internal Medicine facility failed to function when its respective test button was pushed five times. Based on interview at the time of the observations, Maintenance Coordinator acknowledged the aforementioned battery operated emergency lights failing to function when its respective test button was pushed, and immediately radioed in work service orders to the maintenance staff to repair the emergency lights.

Based on observation and interview, the facility failed to maintain protection of 2 of 6 ceiling barriers in accordance of 19.3.1. LSC 19.3.1 requires protection of vertical opening 39.3.1. LSC 19.3.1 requires vertical opening shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 19.3.1.1 requires where an enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. This deficient practice could affect patients, staff, and visitors on the 4th, 5th, and 6th floors.

Findings include:

Based on observations with the Director of Facility Services and Maintenance Coordinator on 04/09/19 between 8:30 a.m. and 12:15 p.m., a four inch conduit penetrated the floor/ceiling assembly between the 6th and 5th floor, and the 5th and 4th floor in the Telecom Room on each floor. The conduit was mostly open with only two small wires running through. Based on interview at the time of observation, the Director of Facility Services agreed the four inch conduit penetrating both floors was not properly fire stopped.

Based on observation and interview, the facility failed to ensure 1 of 1 hazardous area doors, such as a Medical Records storage room door, was provided with a self closing device. This deficient practice could affect all patients, as well as staff and visitors in the building.

Findings include:

Based on observation on 04/10/19 at 10:10 a.m. during a tour of the facility with the Director of Facility Services and RN/MSN, the door to the Medical Records storage room, a storage room over 50 square feet, was not provided with a self closing device. This room was full of paper files. Based on interview at the time of observation, The Director of Facility Services acknowledged the Medical Records storage room door was lacking a self closing device.

Based on observation and interview, the facility failed to ensure 1 of 1 hazardous area doors, such as a storage room door, was provided with a self closing device. This deficient practice could affect all patients, as well as staff and visitors in the suite.

Findings include:

Based on observation on 04/09/19 at 2:01 p.m. during a tour of the facility with the Director of Facility Services and the Maintenance Coordinator, the door to the general storage room, a storage room over 50 square feet, was not provided with a self closing device. This room was full of combustible items, such as, paper, plastic, cardboard boxes, etc. Based on interview at the time of observation, The Director of Facility Services acknowledged the general storage room door was lacking a self closing device.

Based on observation and interview, the facility failed to ensure 1 of 1 hazardous area, such as a storage room over 50 square feet, was provided with a self closing door. This deficient practice could affect all patients, as well as staff and visitors in the suite.

Findings include:

Based on observation on 04/09/19 at 2:48 p.m. during a tour of the facility with the Director of Facility Services and the Maintenance Coordinator, the Durable Medical Equipment (DME) storage room was full of combustible items, such as, paper, plastic totes full of items, and cardboard boxes full of items. This storage room was over 50 square feet and was not provided with a self closing door. Based on interview at the time of observation, The Director of Facility Services acknowledged the DME storage room was not provided with a self closing door.

Based on observation and interview, the facility failed to ensure 1 of 2 hard wired smoke detectors were not installed where air flow would adversely affect its operation. NFPA 72, 2010 edition, 17.7.6.3.2 requires that smoke detectors shall not be located directly in the airstream of supply registers. Section 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening. This deficient practice could affect all clients, as well as staff and visitors in the suite.

Findings include:

Based on observation on 04/09/19 at 2:45 p.m. during a tour of the facility with the Director of Facility Services and Maintenance Coordinator, there was a ceiling mounted smoke detector in the Conference Room within one foot of an air supply vent. Based on interview at the time of observation, the Director of Facility Services agreed the smoke detector was within one foot of the Conference Room air supply vent.

Based on observation and interview, the facility failed to ensure 1 of over 5 hard wired smoke detectors were not installed where air flow would adversely affect its operation. NFPA 72, 2010 edition, 17.7.6.3.2 requires that smoke detectors shall not be located directly in the airstream of supply registers. Section 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening. This deficient practice could affect all patients, as well as staff and visitors in the suite.

Findings include:

Based on observations on 04/09/19 at 2:53 p.m. and again at 2:55 p.m. during a tour of the facility with the Director of Facility Services and the Maintenance Coordinator, there was a ceiling mounted smoke detector in the Waiting Room within 16 inches of an air supply vent, furthermore, there was a ceiling mounted smoke detector between and within one foot of two air supply vents in the Control Room. Based on interview at the time of each observation, the Director of Facility Services acknowledged the smoke detectors were too close to air supply vents.

Based on observation and interview, the facility failed to ensure 36 of over 1000 hard wired smoke detectors were not installed where air flow would adversely affect its operation. NFPA 72, 2010 edition, 17.7.6.3.2 requires that smoke detectors shall not be located directly in the airstream of supply registers. Section 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening. This deficient practice could affect up to 20 patients, as well as staff and visitors throughout the facility.

Findings include:

Based on observations on 04/08/19 between 11:00 a.m. and 4:15 p.m. and on 04/09/19 between 8:30 a.m. and 12:30 p.m. during a tour of the facility with the Director of Facility Services and the Maintenance Coordinator, the following was observed:
a. The Cardiovascular office/EKG file room had a smoke detector within 16 inches of an air supply vent
b. The Heart failure room had a smoke detector within 16 inches of an air supply vent
c. The Prosolo room had a smoke detector within 16 inches of an air supply vent
d. The 6th floor stairwell landing had a smoke detector within 16 inches of an air supply vent
e. The Cardiac back hallway had a smoke detector within 16 inches of an air supply vent
f. The Cath lab holding hall near Holding room #6 had a smoke detector within 16 inches of an air supply vent
g. The Cath lab holding room #8 had a smoke detector within 16 inches of an air supply vent
h. The Cath lab holding room #7 had a smoke detector within 16 inches of an air supply vent
i. The Cath lab holding room #6 had a smoke detector within 16 inches of an air supply vent
j. The Cath lab holding room #5 had a smoke detector within 16 inches of an air supply vent
k. The Cath lab holding room #4 had a smoke detector within 16 inches of an air supply vent
l. The Cath lab holding room #3 had a smoke detector within 16 inches of an air supply vent
m. The Cath lab holding room #2 had a smoke detector within 16 inches of an air supply vent
n. The Cath lab holding room #1 had a smoke detector within 16 inches of an air supply vent
o. Cath lab holding nurses station had a smoke detector within 16 inches of an air supply vent
p. The 6th floor soiled utility room had a smoke detector within 16 inches of an air supply vent
q. The Cath lab equipment room had a smoke detector within 16 inches of an air supply vent
r. The Cath lab Clean storage room had a smoke detector within 16 inches of an air supply vent
s. The Cath lab outside the women's locker room had a smoke detector within 16 inches of an air supply vent
t. The Cath Lab ACC/QI office had a smoke detector within 16 inches of an air supply vent
u. The O.B. room #3458 had a smoke detector within 16 inches of an air supply vent
v. The Surgery Pre-Operative/Post-Operative Room #1 had a smoke detector within 16 inches of an air supply vent
w. The Surgery Pre-Operative/Post-Operative Room #2 had a smoke detector within 16 inches of an air supply vent
x. The Surgery Pre-Operative/Post-Operative Room #3 had a smoke detector within 16 inches of an air supply vent
y. The Surgery Pre-Operative/Post-Operative Room #4 had a smoke detector within 16 inches of an air supply vent
z. The Surgery Pre-Operative/Post-Operative Room #5 had a smoke detector within 16 inches of an air supply vent
aa. The Surgery Pre-Operative/Post-Operative Room #6 had a smoke detector within 16 inches of an air supply vent
bb. The Surgery Pre-Operative/Post-Operative Room #7 had a smoke detector within 16 inches of an air supply vent
cc. The Surgery Pre-Operative/Post-Operative Room #8 had a smoke detector within 16 inches of an air supply vent
dd. The Surgery care nurses station had a smoke detector within 16 inches of an air supply vent
ee. The west end of the Surgical supply room had two smoke detectors within 16 inches of an air supply vent
ff. The 4th floor Nourishment room had a smoke detector within 16 inches of an air supply vent
gg. The 1st floor soiled utility room #1533 near the MRI Center suite had a smoke detector within 12 inches of an air supply vent
hh. The Lower level trash chute room had a smoke detector within 12 inches of an air supply vent
ii. The Lower level Doctors lounge had a smoke detector within 12 inches of an air supply vent
jj. The Lower level BC Storage room had a smoke detector within 12 inches of an air supply vent
Based on interview at the time or each above mentioned observation, the Director of Facility Services and the Maintenance Coordinator agreed each aforementioned smoke detector as being within 36 inches of an air supply vent.

Based on observation and interview, the facility failed to ensure 4 of 4 sprinkler system gauges were replaced every 5 years or documented as tested every 5 years by comparison with a calibrated gauge. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all patients, staff, and visitors in the suite.

Findings include:

Based on observation on 04/10/19 at 9:50 a.m. during a tour of the facility with the Maintenance Coordinator, the facility has supervised wet sprinkler systems and had a total of four water pressure gauges. The manufacture date of 2012 was listed on the face of each sprinkler system gauge. No recalibration date information was affixed to the sprinkler system gauges. Based on interview at the time of the observation, the Maintenance Coordinator stated he did not believe sprinkler system gauges had been recalibrated within the most recent five year period and acknowledged documentation of sprinkler system gauge replacement or recalibration was not available for review for each of the four sprinkler system gauges which were each more than five years old.

Based on observation and interview, the facility failed to ensure 1 of 14 wet locations (exam rooms with sinks) was provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
Informational Note: See 215.9 for ground-fault circuit interrupter protection for personnel on feeders.
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors
Exception No. 1 to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow-melting, deicing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22, as applicable.
Exception No. 2 to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2) shall be permitted for only those receptacle outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection.
(5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink.
Exception No. 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection.
Exception No. 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under
210.8(B)(1), GFCI protection shall not be required.
(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas where electrical
diagnostic equipment, electrical hand tools.
NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have ground-fault circuit interrupter (GFCI) protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect on patient and staff.

Findings include:

Based on observation on 04/10/19 at 9:55 a.m. during a tour of the facility with the Director of Facility Services and RN/MSN, Exam Room #1 had one electric receptacle on the wall within two feet of the sink that was not provided with GFCI protection. This was confirmed when tested with a GFCI testing device. This was acknowledged by the Director of Facility Services at the time of observation.

Based on record review and interview, the facility failed to provide a complete facility specific written fire safety plan for the protection of 82 of 82 patients to accurately address all life safety systems, plus a system addressing all items required by NFPA 101, 2012 edition, Section 19.7.2.2. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
Section 19.2.3.4(4) states any required aisle or corridor shall not be less than 48 inches in clear width where serving as means of egress from patient sleeping rooms. Projections into the required width shall be permitted for wheeled equipment provided the relocation of wheeled equipment during a fire or similar emergency is addressed in the written fire safety plan and training program for the facility. The wheeled equipment is limited to:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
This deficient practice could affect all occupants in the event of an emergency.

Findings include:

Based on a review of the facility's Fire Alarm plan on 04/08/19 between 11:00 a.m. and 4:15 p.m. with the Director of Facility Services, Maintenance Coordinator, and Human Resources Manager/Public Safety person present, the fire safety plan did not address the following items:
a. Evacuation of the smoke compartment
b. The use of the K-class fire extinguisher in the kitchen in relationship with the use of the kitchen overhead extinguishing system
Based on interview at the time of record review, the Director of Facility Services acknowledged and agreed that the fire safety plan did not address the previously mentioned items during a fire or similar emergency, furthermore, the Director of Facility Services said the fire safety plan reviewed was the facility's most recent updated fire safety plan.

Based on observation and interview, the facility failed to ensure an electrical outlet and automatic light switch within 1 of 1 oxygen transfilling and storage room were protected. 2012 NFPA 99 Health Care Facilities Code 5.1.3.3.2 (5) and 5.1.3.3.2 (10) both requires locations for central supply systems and the storage of positive-pressure gases to protect electrical devices from physical damage. A.5.1.3.3.2 (5) states electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing physical damage to the cylinders or containers. For example, the device could be located at or above 5 feet above finished floor or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device as required by this section.
This deficient practice could affect all patients, as well as staff and visitors while on the second floor ICU..

Findings include:

Based on observation on 04/09/19 at 10:25 a.m. during a tour of the facility with the Director of Facility Services, there was one electrical receptacle and one automatic light switch on the wall in the second floor ICU oxygen transfilling room less than five feet above the floor and not protected from potential physical damage. Based on interview at the time of observation, the Director of Facility Services acknowledged the electrical receptacle and automatic light switch were not provided with a protective barrier and agreed they were both less than 5 feet above the floor.

Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage location where transfilling occurs was provided with proper signage, a concrete or ceramic floor, and proper distance from combustible items. NFPA 99, Health Care Facilities Code 2012 Edition, Section 11.5.2.3.1 states oxygen transfilling locations shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire resistive construction.
(2) The area is mechanically vented, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures.
NFPA 99, 11.3.2.3 requires oxidizing gases such as oxygen shall be separated from combustibles by one of the following: (1) a minimum distance of 20 feet. (2) a minimum distance of 5 feet if the required storage location is protected by an automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour.
This deficient practice could affect all patients, as well as staff and visitors on the second floor ICU.

Findings include:

Based on observation on 04/09/19 at 10:25 a.m. during a tour of the facility with the Director of Facility Services, the following was noted within the second floor ICU oxygen transfilling and storage room where three liquid oxygen tanks and over ten oxygen cylinders were being stored:
a. The floor in the oxygen transfilling room was vinyl tile and not concrete or ceramic tile
b. There was no signage on the door to the oxygen transfilling and storage room indicating that oxygen transfilling is occurring
c. There was a large bunch of papers stored in a open plastic container mounted to the wall within two feet of the liquid oxygen tanks.
Based on interview at the time of observation, the Director of Facility Services acknowledged the large bunch of papers stored in mounted plastic container, and an ICU nurse then removed the papers.