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Based on observation the facility failed to ensure protection to hazardous areas as required.

Findings:

On 9/20/2016 at 15:19, a janitors closet was observed to not have a self-closing hardware.

On 9/21/2016 at 10:15 a.m., a janitor closet near human resources office had no self-closing hardware.

NFPA 101, 2000 Edition
Chapter 19
19.3.2.1, 19.3.5.4
One hour fire rated construction (with o 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. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. 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

Based on observation and staff interview it was determined that emergency generator powered lighting could not be confirmed throughout the facility.

Findings:

On 09/20/2016 at 14:55, during a tour of the facility emergency lighting in the facility corridors, exit accesses and exit discharge could not be identified or observed. The exit discharge near the cafeteria did not have emergency egress lighting to a public way.

The maintenance director accompanying the LSC surveyors on tour was interviewed. He was asked what lights in the facility are powered by the generator. He said he knows some of the lights are on generator power but can not identify them.

At 11:43, the monthly and annual logs for inspection of battery powered emergency lighting was requested and not provided.

NFPA 101, 2000 Edition
7.9. 20.2.9.1, 21.2.9.1.
Emergency illumination of at least 11/2 hour duration is provided.

Based on observation it was determined the facility failed to ensure smoke detector(s) are maintained, inspected, and tested.

Findings:

On 9/20/2016 at 15:49, a ceiling smoke detector in operating room #2 was observed to have a plastic cover over it.

The physical plant director acknowledged the plastic cover on the smoke detector in operating room #2.

Based on observation it was determined the facility failed to ensure portable fire extinguishers were installed, inspected and maintained.

Findings:

On 9/20/2016 at 15: 52, two fire extinguishers were observed to be placed unsecured on a foot stool next to the exit within the surgical suite corridor.

On 9/21/2016 at 11:05 a.m., at the PT building, a fire extinguisher was observe tobe installed over 5 feet from the floor.

Portable fire extinguishers shall be installed, inspected, and maintained in all health care occupancies in accordance with 9.7.4.1, NFPA 10.
18.3.5.6, 19.3.5.6

Based on observation, staff interview and record review the facility failed to ensure heating, ventilating, and air conditioning system(s), and smoke evacuation system(s) that comply with NFPA code were installed, tested and maintained.

Findings:

On 9/20/2016 at 14:32, an exhaust vent on the roof of the facility was observed to be installed within approxinately 3-4 feet of the surgical suite fresh air intake.

The physical plant director acknowledged the exhaust vent too close to the surgical suite air intake located on the roof of the facility.

ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities
The exhaust fan is not located at least 25 feet away in accordance with ANI/ASHE 6.3. All vent exhaust fans and alike equipment shall be 25 feet away and 3 feet above the roof line in accordance with ANI/ASHE 6.3.

On 9/21/2016 at 08:15 a.m., on record review of the facility's smoke detection system inspection report dated 1-26-2016 from Simplex Grinnell advised the smoke evacuation system was manually activated. Staff is required to go to the mechanical room penthouse on the roof to manually switch on the smoke evacuation system that serves their surgical suite. Simplex Grinnell recommend the system be automatic.

At 08:32 a.m., the physical operations director was interviewed. He was asked if the smoke evacuation is automatic. He said no he or one of his staff have to climb the ladder to the roof, then go to the mechanical room penthouse to manually switch on the smoke evacuation system.

NFPA 99, 1999 Edition
Chapter 5 Environmental Systems
5-4* Distribution Systems
5-4.1* Ventilation - Anesthetizing Locations
5-4.1.2
Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Based on observation it was determined the facility failed to ensure egress corridors where maintained unobstructed.

Findings:

On 9/20/2016 at 15:54, the egress corridor near materials management was observed to be cluttered with multiple peices of medical equipment stored within the egress corridor.


NFPA 101, 2000 Edition
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10. 18.2.1, 19.2.1

Based on observation, staff interview, and record review, it was determined the facility failed to ensure protection of electrical wiring and equipment as required.

Findings:

On 9/20/2016 at 14:14, 2 open junction boxes were observed in the electrical closet near the maintenance office.

At 9/20/2016 at 15:02, a 4 outlet multiplug, a 3 outlet multiplug and 1 power tap was observed to be in use in the doctor's lounge.

At 15:49, 1 daisy chained extension cord was observed to be in use in operating room #1.

On 9/21/2016 at 9:47 a.m., the snackroom across from patient room 117 was observed to have 2 non-GFCI receptacles within 6ft of a water source.

At 10:45 a.m., two refrigerators were observed to be plugged into a power tap in the emergency room.

At 11:04 a.m., two hydroculators were observed to be plugged into non-GFCI receptacles.


Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

Based on observation the facility failed to ensure protection to hazardous areas as required.

Findings:

On 9/20/2016 at 15:19, a janitors closet was observed to not have a self-closing hardware.

On 9/21/2016 at 10:15 a.m., a janitor closet near human resources office had no self-closing hardware.

NFPA 101, 2000 Edition
Chapter 19
19.3.2.1, 19.3.5.4
One hour fire rated construction (with o 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. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. 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

Based on observation and staff interview it was determined that emergency generator powered lighting could not be confirmed throughout the facility.

Findings:

On 09/20/2016 at 14:55, during a tour of the facility emergency lighting in the facility corridors, exit accesses and exit discharge could not be identified or observed. The exit discharge near the cafeteria did not have emergency egress lighting to a public way.

The maintenance director accompanying the LSC surveyors on tour was interviewed. He was asked what lights in the facility are powered by the generator. He said he knows some of the lights are on generator power but can not identify them.

At 11:43, the monthly and annual logs for inspection of battery powered emergency lighting was requested and not provided.

NFPA 101, 2000 Edition
7.9. 20.2.9.1, 21.2.9.1.
Emergency illumination of at least 11/2 hour duration is provided.

Based on observation it was determined the facility failed to ensure smoke detector(s) are maintained, inspected, and tested.

Findings:

On 9/20/2016 at 15:49, a ceiling smoke detector in operating room #2 was observed to have a plastic cover over it.

The physical plant director acknowledged the plastic cover on the smoke detector in operating room #2.

Based on observation it was determined the facility failed to ensure portable fire extinguishers were installed, inspected and maintained.

Findings:

On 9/20/2016 at 15: 52, two fire extinguishers were observed to be placed unsecured on a foot stool next to the exit within the surgical suite corridor.

On 9/21/2016 at 11:05 a.m., at the PT building, a fire extinguisher was observe tobe installed over 5 feet from the floor.

Portable fire extinguishers shall be installed, inspected, and maintained in all health care occupancies in accordance with 9.7.4.1, NFPA 10.
18.3.5.6, 19.3.5.6

Based on observation, staff interview and record review the facility failed to ensure heating, ventilating, and air conditioning system(s), and smoke evacuation system(s) that comply with NFPA code were installed, tested and maintained.

Findings:

On 9/20/2016 at 14:32, an exhaust vent on the roof of the facility was observed to be installed within approxinately 3-4 feet of the surgical suite fresh air intake.

The physical plant director acknowledged the exhaust vent too close to the surgical suite air intake located on the roof of the facility.

ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities
The exhaust fan is not located at least 25 feet away in accordance with ANI/ASHE 6.3. All vent exhaust fans and alike equipment shall be 25 feet away and 3 feet above the roof line in accordance with ANI/ASHE 6.3.

On 9/21/2016 at 08:15 a.m., on record review of the facility's smoke detection system inspection report dated 1-26-2016 from Simplex Grinnell advised the smoke evacuation system was manually activated. Staff is required to go to the mechanical room penthouse on the roof to manually switch on the smoke evacuation system that serves their surgical suite. Simplex Grinnell recommend the system be automatic.

At 08:32 a.m., the physical operations director was interviewed. He was asked if the smoke evacuation is automatic. He said no he or one of his staff have to climb the ladder to the roof, then go to the mechanical room penthouse to manually switch on the smoke evacuation system.

NFPA 99, 1999 Edition
Chapter 5 Environmental Systems
5-4* Distribution Systems
5-4.1* Ventilation - Anesthetizing Locations
5-4.1.2
Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Based on observation it was determined the facility failed to ensure egress corridors where maintained unobstructed.

Findings:

On 9/20/2016 at 15:54, the egress corridor near materials management was observed to be cluttered with multiple peices of medical equipment stored within the egress corridor.


NFPA 101, 2000 Edition
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10. 18.2.1, 19.2.1

Based on observation, staff interview, and record review, it was determined the facility failed to ensure protection of electrical wiring and equipment as required.

Findings:

On 9/20/2016 at 14:14, 2 open junction boxes were observed in the electrical closet near the maintenance office.

At 9/20/2016 at 15:02, a 4 outlet multiplug, a 3 outlet multiplug and 1 power tap was observed to be in use in the doctor's lounge.

At 15:49, 1 daisy chained extension cord was observed to be in use in operating room #1.

On 9/21/2016 at 9:47 a.m., the snackroom across from patient room 117 was observed to have 2 non-GFCI receptacles within 6ft of a water source.

At 10:45 a.m., two refrigerators were observed to be plugged into a power tap in the emergency room.

At 11:04 a.m., two hydroculators were observed to be plugged into non-GFCI receptacles.


Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1