HospitalInspections.org

Based on interview with the TVHS interim safety director and the facility maintenance man, the facility failed to perform fire drills as required by 19.7.1.2 of the Life Safety Code. This practice affected all residents and staff. Facility census was 10 residents on date of survey.

Findings are:

Observations on 6-10-10 at 6:30PM revealed only one recorded fire drill. Several staff members were trying to find the fire drill records but could not. The one recorded fire drill was noted to be performed on 3-16-10 at 2:43PM and was conducted on the day shift.

During an interview on 6-10-10 at 6:30PM, the staff conveyed to this surveyor that the previous safety director was off of work due to an injury since November and no one could find the files. The only fire drill that was found since that safety directors absence was noted above, conducted on 3-16-10.

The interim safety director stated that this practice will most certainly be corrected and fire drills will resume the normal cycle of at least "one per quarter, per shift."

Based on observation and interview, the facility failed to have sufficient fire detection for all parts of the building. Specifically, no heat or smoke detection behind the large dryers in the laundry room. This practice affected staff only as there are fire separation doors between the laundry and hospital corridor but has the potential to affect patients (depending upon fire conditions). Facility census was 10 patients on date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 at 5:35PM revealed there was no smoke or heat detection behind the dryers in the laundry and this is also a location that does not have fire sprinklers. This is an area with greater potential for fire and a heat or smoke detector that is connected to the fire alarm system is required here.

During an interview on 6-10-10 at 5:35PM, the interim safety director stated that she was not aware of this deficiency and the fire alarm company would be contacted on 6-11-10 to correct this problem.

Based on observation and staff interview, the facility failed to maintain a safe egress pathway / exit discharge with means to a public way for the temporary emergency exit on the south side that was added due to construction of the new building (being built to the southwest). This practice affected all patients and staff as anyone at any given time might need this emergency exit as a primary or secondary means of escape. Facility census was 10 patients on date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 at 4:35PM revealed that the egress pathway for the temporary emergency exit on the south side led to a grassy area and then "bottle-necked" (due to a steel railing) to an area that had many obstructions such as large orange construction barrels, a large cable coming out of the ground to trip on and also wooden stakes that had black fabric for landscaping attached to them (which was vertically installed and was also a trip hazard). This is a problem that has been brought to the facility's attention before and was discussed in length with the and contractor of the construction company.

During an interview on 6-10-10 at 4:35PM, the Interim Safety Director and facility maintenance man stated they were unaware of past problems with this egress path and the ISD directed the maintenance man to fix the problem. The maintenance man did make the situation better by removing major obstacles but I told him to come back and smooth out the path and get rid of any remaining obstructions such as the cable and smaller pieces of debris (that were not removed at the time of survey). The facility was also instructed to talk with the construction crew to make sure they are also aware of the repeat violation and know what needs to be done to ensure a safe escape path.

Record review of State Fire Marshal Order #87162213, dated 12-4-09 Stated:
The current, temporary emergency exit discharge is unacceptable due to obstructions and narrow width. This situation must be corrected as soon as possible.
-Approved means of egress shall be maintained from exiting areas of the building during remodel, alteration, and or addition process. NFPA101, 4.6.10.1
-Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, Courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. (1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit. LSC 7.7.1

Based on documentation review and interview, the facility failed to inspect the generator weekly as directed by NFPA 110, 6-4.1. This practice affected all patients. Facility census was 10 patients on date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 at 6:30PM revealed the facility generator logs included monthly load tests but no record of weekly inspections. This deficiency is important as the facility must ensure that the generator will function properly at the time of emergency need.

During an interview on 6-10-10, the facility maintenance man stated he was unaware that the generator needed to be inspected or ran on a weekly basis but that they would certainly add that to their list of weekly checks.

Record review of TVHS generator logs revealed only monthly load tests had been performed.
---New batteries installed for the generator on 6-3-10.

Based on observations and interview, the facility failed to have the proper electrical equipment for several locations in the facility. This practice affected all patients due to the various locations of this deficiency. Facility census was 10 residents on the date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 between 4:00PM and 6:30PM revealed the following locations which are in or open to the corridor had electrical equipment deficiencies:
1) Security station near safety office - Improper surge strip. (Which is a relocatable power tap / multi-plug electrical surge strip in use that has not been approved by fire codes.)
2) Registration area - Improper surge strips at each desk.
3) Patient bathing room - Improper surge strip.
4) Emergency Room: Improper surge strips x 2 (one is mounted on cart).
5) Nurses station near room 12: Improper surge strip.
6) Operating Room breaker box: Missing a "dummy plate" (there is a hole in the breaker box that needs covered so no one gets an electrical shock).
7) Clean Utility, near room 18: Missing an outlet cover plate.

During an interview on 6-10-10 between 6:30 - 6:40PM, the facility interim safety director stated that the facility is aware of the surge strip / relocatable power tap policy and did not realize that there were still disapproved surge strips in use. The interim safety director stated all the power taps noted will be replaced and agreed that the one in the patient bathing room is a priority. The facility is also double checking with the electricians of the new hospital (currently under construction) to ensure enough hard-wired outlets to avoid the need for relocatable power taps / surge strips in the new building.

Review of NFPA 70, 1999 ed. article 400-8, 517, 110-3(b) and NSFM Interpretation 08-01 revealed that the facility is in a state of non-compliance until all disapproved relocatable power taps are removed from use.

Based on observations and interview, the facility failed to maintain a safe distance for one ABHR dispenser in relation to a potential ignition source (light switch). This practice affected all patients and staff in the affected area. There are 12 hospital beds in the affected area of this dispenser. Facility census was 10 residents on date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 at approximately 4:20PM revealed an ABHR dispenser at the nurses station near the bathing room was installed within twelve inches of a potential ignition source such as the light switch that measured to be 5 inches away.

During an interview on 6-10-10 at approximately 4:20PM, the facility's interim safety director stated that she had been going through the facility to ensure the relocation of the ABHR's that are mounted too close to ignition sources and this is one that must have been missed. She stated it will be relocated as soon as possible and proposed a new location that would be acceptable.

Based on interview with the TVHS interim safety director and the facility maintenance man, the facility failed to perform fire drills as required by 19.7.1.2 of the Life Safety Code. This practice affected all residents and staff. Facility census was 10 residents on date of survey.

Findings are:

Observations on 6-10-10 at 6:30PM revealed only one recorded fire drill. Several staff members were trying to find the fire drill records but could not. The one recorded fire drill was noted to be performed on 3-16-10 at 2:43PM and was conducted on the day shift.

During an interview on 6-10-10 at 6:30PM, the staff conveyed to this surveyor that the previous safety director was off of work due to an injury since November and no one could find the files. The only fire drill that was found since that safety directors absence was noted above, conducted on 3-16-10.

The interim safety director stated that this practice will most certainly be corrected and fire drills will resume the normal cycle of at least "one per quarter, per shift."

Based on observation and interview, the facility failed to have sufficient fire detection for all parts of the building. Specifically, no heat or smoke detection behind the large dryers in the laundry room. This practice affected staff only as there are fire separation doors between the laundry and hospital corridor but has the potential to affect patients (depending upon fire conditions). Facility census was 10 patients on date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 at 5:35PM revealed there was no smoke or heat detection behind the dryers in the laundry and this is also a location that does not have fire sprinklers. This is an area with greater potential for fire and a heat or smoke detector that is connected to the fire alarm system is required here.

During an interview on 6-10-10 at 5:35PM, the interim safety director stated that she was not aware of this deficiency and the fire alarm company would be contacted on 6-11-10 to correct this problem.

Based on observation and staff interview, the facility failed to maintain a safe egress pathway / exit discharge with means to a public way for the temporary emergency exit on the south side that was added due to construction of the new building (being built to the southwest). This practice affected all patients and staff as anyone at any given time might need this emergency exit as a primary or secondary means of escape. Facility census was 10 patients on date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 at 4:35PM revealed that the egress pathway for the temporary emergency exit on the south side led to a grassy area and then "bottle-necked" (due to a steel railing) to an area that had many obstructions such as large orange construction barrels, a large cable coming out of the ground to trip on and also wooden stakes that had black fabric for landscaping attached to them (which was vertically installed and was also a trip hazard). This is a problem that has been brought to the facility's attention before and was discussed in length with the and contractor of the construction company.

During an interview on 6-10-10 at 4:35PM, the Interim Safety Director and facility maintenance man stated they were unaware of past problems with this egress path and the ISD directed the maintenance man to fix the problem. The maintenance man did make the situation better by removing major obstacles but I told him to come back and smooth out the path and get rid of any remaining obstructions such as the cable and smaller pieces of debris (that were not removed at the time of survey). The facility was also instructed to talk with the construction crew to make sure they are also aware of the repeat violation and know what needs to be done to ensure a safe escape path.

Record review of State Fire Marshal Order #87162213, dated 12-4-09 Stated:
The current, temporary emergency exit discharge is unacceptable due to obstructions and narrow width. This situation must be corrected as soon as possible.
-Approved means of egress shall be maintained from exiting areas of the building during remodel, alteration, and or addition process. NFPA101, 4.6.10.1
-Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, Courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. (1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit. LSC 7.7.1

Based on documentation review and interview, the facility failed to inspect the generator weekly as directed by NFPA 110, 6-4.1. This practice affected all patients. Facility census was 10 patients on date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 at 6:30PM revealed the facility generator logs included monthly load tests but no record of weekly inspections. This deficiency is important as the facility must ensure that the generator will function properly at the time of emergency need.

During an interview on 6-10-10, the facility maintenance man stated he was unaware that the generator needed to be inspected or ran on a weekly basis but that they would certainly add that to their list of weekly checks.

Record review of TVHS generator logs revealed only monthly load tests had been performed.
---New batteries installed for the generator on 6-3-10.

Based on observations and interview, the facility failed to have the proper electrical equipment for several locations in the facility. This practice affected all patients due to the various locations of this deficiency. Facility census was 10 residents on the date of survey, 6-10-10.

Findings are:

Observations on 6-10-10 between 4:00PM and 6:30PM revealed the following locations which are in or open to the corridor had electrical equipment deficiencies:
1) Security station near safety office - Improper surge strip. (Which is a relocatable power tap / multi-plug electrical surge strip in use that has not been approved by fire codes.)
2) Registration area - Improper surge strips at each desk.
3) Patient bathing room - Improper surge strip.
4) Emergency Room: Improper surge strips x 2 (one is mounted on cart).
5) Nurses station near room 12: Improper surge strip.
6) Operating Room breaker box: Missing a "dummy plate" (there is a hole in the breaker box that needs covered so no one gets an electrical shock).
7) Clean Utility, near room 18: Missing an outlet cover plate.

During an interview on 6-10-10 between 6:30 - 6:40PM, the facility interim safety director stated that the facility is aware of the surge strip / relocatable power tap policy and did not realize that there were still disapproved surge strips in use. The interim safety director stated all the power taps noted will be replaced and agreed that the one in the patient bathing room is a priority. The facility is also double checking with the electricians of the new hospital (currently under construction) to ensure enough hard-wired outlets to avoid the need for relocatable power taps / surge strips in the new building.

Review of NFPA 70, 1999 ed. article 400-8, 517, 110-3(b) and NSFM Interpretation 08-01 revealed that the facility is in a state of non-compliance until all disapproved relocatable power taps are removed from use.