HospitalInspections.org

Based on observation, the facility failed to maintain a fire barrier wall in accordance with the requirements at NFPA 101 (00) Chapter 19, Section 19.1. In a fire emergency, this deficient practice could adversely affect all patients, visitors and staff within the affected smoke compartment.

Findings include:

On 6/12/12 at 2:10 PM, observation revealed that the cross-corridor fire doors at the 2-hour fire wall separating the hospital from the Maplewood Professional Building, consisted of labeled 1 1/2 hour self closing doors that positively latched only at the top of the doors.
Document that this labeled door assembly meets NFPA 80 (99), Standard for Fire Doors and Fire windows, or repair the doors to latch at both the top and bottom.
Also, it could not be confirmed whether or not that these fire doors were interconnected to the hospital fire alarm system.

Based on observations, the facility has failed to provide proper protection from 2 hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect residents on 2 of 4 floors, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am, on 6/12//12, it was observed that:

1) The Physical Therapy equipment/storage/staff room on the fourth floor is 11 ft x 14 ft, and is used for storing quantities of combustible supplies. This door is not equipped with a automatic self closing device.

2) The door to Storage Room 408,is larger than 50 sq. ft. and is used for storing quantities of combustible supplies. This door is not equipped with a automatic self closing device.


These findings were observed by the Maintenance Engineer during the facility tour.

Based on observation, the handrail to the hard surface is not provided from the exit to the public way in conformance with NFPA 101-2000 Edition, Sections 7.1, 7.1.10 and 7.5.4. This deficient practice could affect all occupants including patients staff and visitors.

Findings include:
On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am, observation revealed that the exterior stairs exiting from the center stairwell exit to the outside does not have a handrail on the stairs.

Based on observations, it was determined that the facility has failed to ensure that the exterior exit discharge path is provided with illumination in accordance with the NFPA 101, 2000 Ed., Sections 19.2.8 and 7.8.1.4. This deficient practice could affect all residents, staff and visitors, if emergency exiting of the facility were necessary.

Findings include:
On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am, on 6/12//12, it was observed that the exterior sidewalk beginning at the center stairwell that leads to the public way does not have approved lighting of the egress path.

Based on review of the fire emergency plan and observation by MDH surveyors, the facility has failed to follow the requirements of their Skin Prep policy No. O-31, in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients, staff and visitors of the smoke compartment that may be affected by a fire.

It was observed by MDH surveyors that on Tuesday, 6/12/12, at 07:51 AM, during a surgery procedure in OR #1, that an alcohol based skin prep product was applied to the patients skin and the patient was then immediately draped without allowing sufficient time for the skin prep soloution to completely dry according to the manufactures directions.
This is a violation of hospital policy for surgical procedures and product directions in an oxygen enriched environment.

Based on observation, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7: NFPA 13 - 1999 edition, Sections 5-1.1 and 5-6.5.2.3. This deficient practice could affect all Patients, staff and visitors.

Findings include:

On facility tour between 2:00 PM and 4:00 PM on 6/10/2012, and 9:00 AM to 11:00 AM, it was observed that:

1) The escutcheon plate around the sprinkler head in the Storage Room on the South 4th floor was missing, and

2) The fire sprinkler head in the electrical panel room across from the 4th Floor Nurse Station has a pendent style head that is approximately 4 feet below the roof deck, and this exceeds the allowable distance a pendent head is allowed to be located below a ceiling/ roof assembly.

This finding was observed by Maintenance Engineer during the facility tour.

Based on record review, the facility failed to install the medical gas system in accordance with the requirements of NFPA 101 - 2000 edition, Section 19.3.2.4 and NFPA 99 Section 4 - 1999 edition, This deficient practice could affect all Patients, staff and visitors.

Findings include:
On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 AM to 11:00 AM, on 6/12//12, it was noted during the review of available medical gas maintenance records, that the annual medical gas system inspection dated 03/10/2012 did not identify, or inspect, the Sterile Processing Medical Gas System zone.
This finding was observed by Maintenance Engineer during the facility tour.

Based on review of records,the facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:

On facility tour and documentation review and in an interview with the Chief Engineer between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am on 6-12-12, revealed that:

1) The monthly test records of the generators indicated the transfer of some of the loads to the generator took longer than 10 seconds.

2) The monthly testing under load of the two generators indicated that the load was not 30 % of the generator's capacity, and that no load bank test documentation was available indicating that the test has been done annually.

Based on observation, the facility failed to maintain a fire barrier wall in accordance with the requirements at NFPA 101 (00) Chapter 19, Section 19.1. In a fire emergency, this deficient practice could adversely affect all patients, visitors and staff within the affected smoke compartment.

Findings include:

On 6/12/12 at 2:10 PM, observation revealed that the cross-corridor fire doors at the 2-hour fire wall separating the hospital from the Maplewood Professional Building, consisted of labeled 1 1/2 hour self closing doors that positively latched only at the top of the doors.
Document that this labeled door assembly meets NFPA 80 (99), Standard for Fire Doors and Fire windows, or repair the doors to latch at both the top and bottom.
Also, it could not be confirmed whether or not that these fire doors were interconnected to the hospital fire alarm system.

Based on observations, the facility has failed to provide proper protection from 2 hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect residents on 2 of 4 floors, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am, on 6/12//12, it was observed that:

1) The Physical Therapy equipment/storage/staff room on the fourth floor is 11 ft x 14 ft, and is used for storing quantities of combustible supplies. This door is not equipped with a automatic self closing device.

2) The door to Storage Room 408,is larger than 50 sq. ft. and is used for storing quantities of combustible supplies. This door is not equipped with a automatic self closing device.


These findings were observed by the Maintenance Engineer during the facility tour.

Based on observation, the handrail to the hard surface is not provided from the exit to the public way in conformance with NFPA 101-2000 Edition, Sections 7.1, 7.1.10 and 7.5.4. This deficient practice could affect all occupants including patients staff and visitors.

Findings include:
On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am, observation revealed that the exterior stairs exiting from the center stairwell exit to the outside does not have a handrail on the stairs.

Based on observations, it was determined that the facility has failed to ensure that the exterior exit discharge path is provided with illumination in accordance with the NFPA 101, 2000 Ed., Sections 19.2.8 and 7.8.1.4. This deficient practice could affect all residents, staff and visitors, if emergency exiting of the facility were necessary.

Findings include:
On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am, on 6/12//12, it was observed that the exterior sidewalk beginning at the center stairwell that leads to the public way does not have approved lighting of the egress path.

Based on review of the fire emergency plan and observation by MDH surveyors, the facility has failed to follow the requirements of their Skin Prep policy No. O-31, in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients, staff and visitors of the smoke compartment that may be affected by a fire.

It was observed by MDH surveyors that on Tuesday, 6/12/12, at 07:51 AM, during a surgery procedure in OR #1, that an alcohol based skin prep product was applied to the patients skin and the patient was then immediately draped without allowing sufficient time for the skin prep soloution to completely dry according to the manufactures directions.
This is a violation of hospital policy for surgical procedures and product directions in an oxygen enriched environment.

Based on observation, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7: NFPA 13 - 1999 edition, Sections 5-1.1 and 5-6.5.2.3. This deficient practice could affect all Patients, staff and visitors.

Findings include:

On facility tour between 2:00 PM and 4:00 PM on 6/10/2012, and 9:00 AM to 11:00 AM, it was observed that:

1) The escutcheon plate around the sprinkler head in the Storage Room on the South 4th floor was missing, and

2) The fire sprinkler head in the electrical panel room across from the 4th Floor Nurse Station has a pendent style head that is approximately 4 feet below the roof deck, and this exceeds the allowable distance a pendent head is allowed to be located below a ceiling/ roof assembly.

This finding was observed by Maintenance Engineer during the facility tour.

Based on record review, the facility failed to install the medical gas system in accordance with the requirements of NFPA 101 - 2000 edition, Section 19.3.2.4 and NFPA 99 Section 4 - 1999 edition, This deficient practice could affect all Patients, staff and visitors.

Findings include:
On facility tour between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 AM to 11:00 AM, on 6/12//12, it was noted during the review of available medical gas maintenance records, that the annual medical gas system inspection dated 03/10/2012 did not identify, or inspect, the Sterile Processing Medical Gas System zone.
This finding was observed by Maintenance Engineer during the facility tour.

Based on review of records,the facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:

On facility tour and documentation review and in an interview with the Chief Engineer between 2:00 PM and 4:00 PM on 6/11/2012, and 9:00 am to 11:00 am on 6-12-12, revealed that:

1) The monthly test records of the generators indicated the transfer of some of the loads to the generator took longer than 10 seconds.

2) The monthly testing under load of the two generators indicated that the load was not 30 % of the generator's capacity, and that no load bank test documentation was available indicating that the test has been done annually.