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Based on Life Safety Code (LSC) survey, Union Hospital Building 01, 02, 03, 04, 07, 08 and Building 10 were found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 18, New Health Occupancies.

Union Hospital is comprised of the main hospital in Terre Haute, IN (Building 01), the east building in Terre Haute, IN (Building 02), Hux Cancer Center in Terre Haute, IN (Building 04), Wabcash Valley Surgery Center in Terre Haute, IN (Building 07), Union Hospital Cath Lab in Terre Haute, IN (Building 08) and Therapy Services in Terre Haute, IN (Building 10).

Union Hospital-West Building (Building 01), a four story fully sprinklered building with a Penthouse and lower level of Type I (332) construction with a monitored fire alarm system with smoke detection in the corridors, areas open to the corridors and all patient rooms. Building 01 provides overnight care. Buildings 01 and 02 have a combined capacity of 257 and had a census of 234 at the time of this survey.

Union Hospital-East Building (Building 02), a four story fully sprinklered building with a lower level of Type (332) construction with a monitored fire alarm system with smoke detection in the corridors and areas open to the corridors. Building 02 provides overnight care. Buildings 01 and 02 have a combine capacity of 257 and had a census of 234 at the time of this survey.

Union Hospital Hux Cancer Ctr Chemotherapy Services (Building 04), located on the 3rd floor of a three story fully sprinklered building with a basement of Type II (000) construction with a monitored fire alarm system with smoke detection in the corridors. Building 04 provides services during regular business hours.

Wabash Valley Surgery Center (Building 07), a one story fully sprinklered building of Type II (111) construction with a monitored fire alarm system with smoke detection in the corridors. Building 07 provides ambulatory surgical services with no overnight stays.

Union Hospital Cathlab Ser Providence Med Ste S (Building 08), located on the 1st floor of a two story fully sprinklered building of Type V (111) construction with a monitored fire alarm system with smoke detection in the corridors. Building 08 provides surgical services with no overnight stays.

Therapy Services (UAP Bone & Joint) (Building 10), located on the 1st floor of a two story fully sprinklered building of Type V (000) construction with a monitored fire alarm system with smoke detection in the corridors. Building 10 provides services during regular business hours.
Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 2 of 7 fire barriers to nonconforming buildings were protected by a two hour fire wall (Building 02) (see K 011), failed to ensure 8 of over 25 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception(Buildings 01 & 02) (see K 017), failed to ensure 1 of 1 fire alarm systems was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. (Building 08) (see K 052), failed to ensure a complete automatic sprinkler system or alternative automatic extinguishing equipment was provided for 2 of 2 elevator machine rooms in this five story building of Type I (332) construction which is required to be fully sprinklered (Building 02) (see K 056), failed to ensure quarterly sprinkler inspections were conducted for the sprinkler system for 3 of 4 calendar quarters (Building 08) (see K 062), failed to ensure 2 of 3 kitchen exhaust systems was maintained in proper working order(Building 02) (see K 069), failed to maintain system integrity for 4 of 4 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition (Building 01, 02, 07 & 08) (see K077), failed to ensure 6 of 6 automatic sprinkler system's gauges were continuously maintained in reliable operating condition, inspected and tested periodically, failed to maintain 3 of over 15 smoke detectors in accordance with NFPA 72, failed to ensure 2 of over 10 alcohol based hand sanitizers was not installed over an ignition source & failed to ensure at least two hour tenant separation from adjoining occupancies (Building 04 & 08) (see K 130) and failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop, failed to ensure a monthly load test for the emergency generator was conducted for 12 of 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer and failed to provide emergency task lighting in and around 1 of 1 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code (Building 07, 08 and 10) (see K 144).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation and interview, the facility failed to ensure storage of infectious waste in a secure area in 4 (Intensive Care Unit [ICU], Medical Surgical/Telemetry Units 3EA, 4EA, 2EA) of 13 areas toured.

Findings:

1. Policy: 187, Infectious Waste Management, revised/reviewed on 2/16 indicated on page 3, infectious waste will be stored in a secure area for final disposition in leak-proof, puncture-resistant containers, identified by a biohazard sticker or sign, and in a temperature controlled, secured area.

2. During tour of units 3EA and 4EA on 6/6/16 at approximately 1400 and 1500 hours, accompanied by staff N1 (Director of Critical Care), the soiled utility rooms containing infectious waste were observed unlocked/unsecured. During tour of units ICU and 2EA on 6/7/16 at approximately 1130 and 1200 hours, accompanied by staff N1, the soiled utility rooms containing infectious waste were observed unlocked/unsecured.

3. While on tour of facility on 6/6/16 at approximately 1400 hours, staff N1 confirmed soiled utility rooms were not locked and accessible by staff without secured entry.

4. On 6/7/16 at approximately 1600 hours, staff N2 (Infection Control Preventionist) confirmed soiled utility rooms observed on tour were unlocked and contained infectious waste. Staff N2 confirmed facility was not following Policy 187, Infectious Waste Management.

Based on observation, and interview; the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location, the facility failed to ensure a monthly load test for the emergency generator was conducted for 12 of 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction, the facility failed to ensure a complete written record of weekly inspections of the starting batteries for the emergency generator was maintained for 52 of 52 weeks. Chapter 3-4.4.1.3 of NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires checking storage batteries, including electrolyte levels, at intervals of not more than 7 days. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction, the facility failed to ensure emergency power would be transferred to the emergency generator within 10 seconds of building power loss for 12 of 12 months. NFPA 99, 3-4.1.1.8 states generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building and the facility failed to provide emergency task lighting in and around 1 of 1 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting.

Findings include;

1. Based on observation of generator equipment on 06/09/16 at 1:45 p.m. with the Plant Director, a remote shut off device was not found for the generator located at the southeast corner of the building. The generator were installed new after 2003 and would require an emergency stop. Based on interview concurrent with the observation with the Plant Director, it was acknowledged the facility was not aware a remote shut off for the generator was required.


2. Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of monthly load testing for the most recent twelve month period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged documentation of monthly load testing for the most recent twelve month period was not available for review.

3. Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of weekly inspections of the starting batteries for the emergency generator for the most recent 52 week period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged documentation of weekly inspections of the starting batteries for the emergency generator for the most recent 52 week period was not available for review.

4. Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of emergency generator transfer time for the most recent twelve month period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged emergency generator transfer time for the most recent twelve month period was not available for review.

5. Based on observation with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the 100 kW emergency generator located outside the building lacked a remote shut off device. Manufacturer's information affixed to the nameplate of the emergency generator indicated the unit was manufactured March 2007. Based on interview at the time of observation, the Maintenance Director acknowledged there was no remote shut off device for the emergency generator.

6. Based on observation on 06/09/16 at 3:15 p.m. with the Plant Director, the generator set location outside the north side of the building lacked battery powered emergency lighting in or around the generator. Based on interview concurrent with the observation was acknowledged by the Plant Director there was no battery powered emergency light available for the generator.

Based on document review, interview and observation the facility failed to ensure the communicating opening was maintained in 2 of 7 fire barriers in the tenant separation walls, the facility failed to ensure 8 of over 25 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception, the facility failed to ensure 3 of over 100 offices were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. Table 7-3.2 shall apply. Table 7-3.2 "Testing Frequencies" requires alarm initiating devices, alarm notification appliances, batteries, and initiating devices to be tested at least annually, the facility failed to ensure all smoke detectors were maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked); the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced, the facility failed to ensure a complete automatic sprinkler system or alternative automatic extinguishing equipment was provided for 2 of 2 elevator machine rooms in this five story building of Type I (332) construction which is required to be fully sprinklered, the facility failed to ensure quarterly sprinkler inspections were conducted for the sprinkler system for 3 of 4 calendar quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code to be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-8 requires records of inspections and tests of the sprinkler system and its components shall be made available to the authority having jurisdiction upon request, the facility failed to ensure 2 of 3 kitchen exhaust systems was maintained in proper working order. NFPA 96, 10-6.5 requires inspection and testing of the total operation and all safety interlocks in accordance with the manufacturer's instructions shall be performed by qualified service personnel a minimum of once every 6 months or more frequently if required, the facility failed to maintain system integrity for 4 of 4 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained, the facility failed to ensure 6 of 6 automatic sprinkler system's gauges were continuously maintained in reliable operating condition, inspected and tested periodically. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 25, 2-3.2 requires 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, the facility failed to maintain 3 of over 15 smoke detectors in accordance with NFPA 72. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening, the facility failed to ensure 1 of 1 oxygen storage locations of greater than 3,000 cubic feet was enclosed with separation of 1 hour fire resistive construction. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 8.2.3.2.1 requires doors in fire barriers shall be of an approved type with the appropriate fire protection rating. Further, 8.2.3.2.1(b) requires fire doors to be self-closing or automatic closing in accordance with 7.2.1.8. and the facility failed to ensure at least two hour tenant separation from adjoining occupancies. NFPA 101, Section 19.1.1.3 requires all health facilities to be designed constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Section 19.1.2.3 states health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours.

Findings include;

1. Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, the set of wood corridor doors in the tenant separation wall at the third floor walkway to the POB had no affixed fire resistance rating and were not equipped with a latching mechanism to latch the door set into the door frame. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned corridor door set in the tenant separation fire barrier did not maintain the fire resistance rating of the fire barrier and did not latch into the door frame.

2. Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, the set of corridor doors in the fire barrier wall by Room 4178 had a 90 minute fire resistant label affixed to each door and were each equipped with a latching mechanism to latch each door into the door frame but the north door latching mechanism failed to protrude into the latching plate. Based on interview at the time of the observations, the Facility Manager acknowledged the north door in the aforementioned corridor door set did not latch into the door frame. Based on review of facility blueprint information with the Director at 10:30 a.m. on 06/09/16, the fire barrier wall by Room 4178 in which the aforementioned communicating opening door set was installed had a fire resistance rating of two hours.

3. Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, the Union West Admitting area, the Wound Care Waiting area, the Work Room in PEDS, the three 5th floor Union West Sub Nurses' Stations (no longer in use as Nurses' Stations), and the 5th floor Union West Waiting area, were open to the corridor. Exception #1 requirement (c) of LSC 19.3.6.1 was not met as follows: The Union West Admitting area, the Wound Care Waiting area, the Work Room in PEDS, the three 5th floor Union West Sub Nurses' Stations (no longer in use as Nurses' Stations), and the 5th floor Union West Waiting area were not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from the nurses' station or similar staffed space. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

4. Based on an observations with the Director of Facilities and the Facilities Manager on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility, the following was observed:
A. Union West room 317 office had a 3 ft. by 3 ft. sliding glass window with a 1/2 inch gap between the window panes when closed
B. Union West empty office at C Wing on 5th floor had a 3 ft. by 3 ft. sliding glass window with a 1/2 inch gap between the window panes when closed
C. Union West Security Office on 5th floor had two, 2 1/2 ft. by 2 1/2 ft. sliding glass windows with 1/2 inch gaps between the window panes when closed
Exception # 6, requirement (a) of the LSC Section 19-3.6.1 was not met because the previously mentioned offices were not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation, furthermore, the Director of Facilities said these offices were not 24 hour stations.

5. Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, the Union East 1st floor Satellite Cafe was open to the corridor. Exception #1 requirement (c) of LSC 18.3.6.1 was not met as follows: The Union East 1st floor Satellite Cafe was not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from nurses' stations or similar staffed space. This was acknowledged by the Director of Facilities at the time of observation.

6. Based on record review with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, fire alarm system testing documentation within the most recent twelve month period was not available for review. Based on interview at the time of record review, the RNS acknowledged fire alarm system testing documentation within the most recent twelve month period was not available for review.

7. Based on record review with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of smoke detector sensitivity testing within the most recent two year period was not available for review. Based on interview at the time of record review, the RNS acknowledged sensitivity testing documentation for all facility fire alarm system smoke detectors within the most recent two year period was not available for review.

8. Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, each of the two fourth floor elevator equipment rooms identified as Room B457 and Room D460 were not provided with sprinkler coverage or alternative automatic extinguishing equipment. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned fourth floor elevator machine rooms were not provided with sprinkler coverage or alternative automatic extinguishing equipment.
9. Based on review of Tri-State Fire Protection "Fire Sprinkler Inspection Report" documentation dated 12/12/15 with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of quarterly sprinkler inspection for the third quarter (July, August, September) 2015, the first quarter (January, February, March) 2016 and the second quarter (April, May, June) 2016 was not available for review. Based on observations with the RNS and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, hanging tags affixed to the sprinkler system riser by Tri-State to document sprinkler inspections did not indicate quarterly sprinkler inspections had been documented for the aforementioned three calendar quarters. Based on interview at the time of record review and of the observations, the RNS and the Maintenance Director acknowledged documentation of quarterly sprinkler inspection for the third quarter 2015 and the first and second quarter 2016 was not available for review.

10. Based on record review on 06/07/16 at 3:45 p.m. with the Compliance/Risk Manager present, the 07/16/15 and 01/21/16 kitchen range hood inspection reports noted "Cooking equipment not properly protected by nozzles". This was acknowledged by Compliance/Risk Manager at the time of record review. Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities the exhaust system nozzles for the two range hoods located within the kitchen were not properly positioned over the cooking equipment under the hoods. All of the nozzles were pointed in front of the cooking equipment. This was acknowledged by the Director of Facilities at the time of each observation.
11. Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 65 deficiencies were listed for the piped gas system's station outlets/inlets and zone valves. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.
12. Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 28 deficiencies were listed for the piped gas system's medical air compressor system, medical vacuum system, nitrous oxide manifold system, nitrogen manifold system, carbon dioxide manifold system, master alarm signal activation and station outlets/inlets. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.
13. Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 14 deficiencies were listed for the piped gas system's medical oxygen manifold system, medical air manifold system, nitrous oxide manifold system, nitrogen manifold system and station outlets/inlets. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.
14. Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the following was noted for the facility's piped gas system location:
a. the entry door from the corridor had no oxygen storage sign on the door, had no fire resistance rating affixed to the door and was not equipped with a self-closing device.
b. the walls and ceiling of the storage room consisted of two layers of 3/8th inch drywall which did not provide one hour fire resistance rating for the room.
c. two sprinkler escutcheons were missing which caused a two one inch diameter holes in the ceiling and failed to separate the room from other spaces with one hour fire resistance.
d. the two inch annular space surrounding each of two one inch in diameter pipes which penetrated the wall above the piped gas system were not firestopped which failed to separate the room from other spaces with one hour fire resistance.
e. no mechanical ventilation was provided.
Based on interview at the time of the observations, the RNS stated less than 2200 cubic feet of oxygen is typically stored in the piped gas system room and acknowledged no signage was provided on the door, had no mechanical ventilation and the room was not separated from other spaces with fire resistant construction of at least one hour.

15. Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, five sprinkler gauges at the sprinkler system riser each had manufacture dates of greater than five years old listed on the gauge. One gauge was listed as 2005, two were listed as 2006 and two were listed as 2007. In addition, the sprinkler gauge on sprinkler piping in the exit stairwell on the first floor by the elevator machine room had a manufacture date of 2006. Based on interview at the time of record review, the Facility Manager stated each of the aforementioned sprinkler systems gauges had been retested within the most recent five year period by comparison with a calibrated gauge, retesting documentation was available at the Facility Manager Office but acknowledged the retesting date was not affixed to each of the gauges. Based on record review with the Union Hospital Facilities Manager Assistant at 2:15 p.m. on 06/09/16, sprinkler system gauge retesting documentation within the most recent five year period was not available for review.

16. Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, the smoke detector on the ceiling in the CT Simulation Room on the ground floor was located one foot from an air supply vent. In addition, each of two smoke detectors installed on the ceiling in Room 104 on the ground floor was located one foot from an air supply vent. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned smoke detector locations were installed less than three feet from an air supply vent.

17. Based on observation with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, one liquid oxygen container was stored in the first floor oxygen storage and transfilling room by the southeast stairwell. The corridor door to the room had no affixed fire resistance rating label. Based on interview at the time of observation, the Facility Manager acknowledged the corridor entry door to the oxygen storage and transfilling room did not enclose the area one hour fire resistive construction.
18. Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, a two foot high by three foot long section of drywall was missing above the suspended ceiling at the main entrance to the facility. In addition, a two foot high by six foot long section of drywall and a two foot high by four foot long section of drywall was missing above the suspended ceiling by the clean storage room. Based on interview at the time of the observations, the RNS and the Maintenance Director acknowledged the aforementioned openings in the tenant separation fire barrier above the suspended ceiling failed to separate the facility from adjoining occupancies with a fire resistance rating of not less than two hours.

Based on observation and interview, the facility failed to ensure 2 of over 10 alcohol based hand sanitizers was not installed over an ignition source. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 101, in 19.1.1.3 requires all health facilities to be designed, constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. This deficient practice could affect over 10 staff and visitors.

Findings include:

1. Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, an alcohol based hand sanitizer was installed directly above a light switch in the reception area for Patient Accounts and at the entrance to Patient Accounts by the stairwell on the lower level. Each of the aforementioned two hand sanitizers had ethyl alcohol stated as an ingredient on its packaging. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned hand sanitizer locations were alcohol based and were installed over an ignition source.

Based on document review and interview, the hospital failed to ensure regular preventive maintenance (PM) for 3 pieces of equipment (2 eyewash stations and dishwasher).

Findings:

1. Review of the policy titled Preventive Maintenance Program indicated the following:
a. Preventative [sic] maintenance service intervals are determined by the manufacturers recommendation...
b. In the absence of manufactures service recommendations, a risk analysis shall be performed on the equipment to determine preventative maintenance requirements and frequency.
c. The policy was effective 2/16

2. On 6/7/16 between 2:00pm and 3:00pm, during facility tour, in the presence of A27, Director of Supply Chain, the following was observed:
a. In the Biomedical Engineering room was an eyewash station.
b. In the Dirty Linen area of the laundry department was an eyewash station.

4. Review of eyewash station PM documentation & logs indicated the following:
a. Tasks: Weekly PM for eyewash stations and decontamination showers
b. Perform a weekly inspection of all eyewash stations...
c. Date 4/5/16 was the most recent PM of biomedical engineering was 4/26/16 and the laundry eyewash station was on 4/5/16.

5. Review of the dishwasher manufacturer Operation Checks indicated 11 (eleven) Weekly PM checks/inspections should be performed.

6. On 6/8/16 at 2:30pm, A7, Clinical Nurse Specialist, indicated the hospital did not have documentation of weekly PM for the dishwasher(s) and indicated the 2 eyewash station PMs were not completed weekly as per their PM schedule.