HospitalInspections.org

This is a Condition Level Deficiency

Based on observation and staff interview, it was determined the facility failed to ensure the any area having a higher degree of hazard for the hospital was sprinkler protected or protected by one hour fire resistance rating. Failure to ensure the areas within the facility are protected has potential to harm patients and staff during a fire.

NFPA 101 2012 Edition, Section 19.1.6 "Minimum Construction Requirements." Section 19.1.6.1 "Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 (See 8.2.1)." Section 8.7.1.1 " Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3. (2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7. (3) Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.3.1.2 " Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Findings Include:

Observation on tour of the facility on August 06, 2019, revealed areas of the hospital that had areas that had a higher degree of hazard, and were not protected with one hour fire resistance rating or protected with an automatic extinguishing system. The building construction of the facility is II (111).

The COO and Support Services Manager acknowledged during the exit conference on August 06, 2019, that there were areas of the hospital that had areas that had a higher degree of hazard, and were not protected with one hour fire resistance rating, or protected with an automatic extinguishing system.

Based on observation and interview with staff, it was determined the facility failed to maintain a clear and unobstructed corridor. Blocked exits and unsecured equipment in the corridors has potential harm to the patients and staff in the event of an emergency.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.3.4 "Any required aisle, corridor, or ramp shall not be less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met: (a) The fixed furniture is securely attached to the floor or to the wall. (b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830mm), except as permitted by 19.2.3.4(2). (c) The fixed furniture is located only on one side of the corridor. (d) The fixed furniture is grouped such that each grouping is not does not exceed an area of 50 ft* (4.6 m*). (e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by by a distance of at least 10 ft (3050 mm). (f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment."

Findings include:

Observation on tour of the facility on August 06, 2019, revealed five vital sign monitors, four chairs, and ten trash/soiled linen containers in the corridors were not in immediate use, and not life saving equipment.

The Chief Operating Officer (COO) and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that the five vital sign monitors, four chairs, and ten trash/soiled linen containers in the corridors e not in immediate use, and not life saving equipment.

Based on record review and interview with staff, it was determined the facility did not have documented evidence that the kitchen hood system was inspected semi-annually in accordance with NFPA 96. Failing to inspect the kitchen hood entire fire extinguishing system semi-annually could allow a build-up of grease and provide fuel for a fire. A fire in the kitchen has potential to harm the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... "Chapter 11, Procedures for the use , Inspection, Testing, and Maintenance of Equipment. Section 11.2 "Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices hood exhaust plenums and a exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least 6 months."

Findings Include:

The fire suppression system for the kitchen hood system was requested on August 06, 2019. The facility was unable to provide documented evidence that the fire extinguishing system was inspected in accordance with NFPA 96 Edition semi-annually from January to December 12, 2018.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation that the fire extinguishing system was inspected in accordance with NFPA 96 Edition semi-annually from January to December 12, 2018.

Based on record review, observation on tour and interview with staff, it was determined the facility failed to:

1. ensure that automatic sprinkler and standpipe systems were installed, inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems; and

2. ensure a five year Internal obstruction test was conducted.

Failure to ensure that sprinklers were maintained throughout the facility according to NFPA 25 standards and an Internal Obstruction test was conducted at required intervals poses potential risk to health and safety if the required prevention of fire systems are not maintained and working.

1. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems. NFPA 25, 2011 Edition, Section 5.3.3 "Waterflow Alarm Devices" Section 5.3.3.2 "Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. Section 5.3.3.5 "Testing waterflow alarm devices on dry pipe, preaction, or deluge systems shall be accomplished by using the bypass connection."

Findings include:

The fire sprinkler system maintenance and inspection records were requested on August 06, 2019. The records indicated the system was not tested semiannually in 2018. Documentation provided was dated 12/13/2018 and 02/20/2018.

The COO and Support Services Manager acknowledged during the exit conference on August 06, 2019, that the fire sprinkler system was not tested semiannually in 2018. Documentation provided was dated 12/13/2018 and 02/20/2018.

2. NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.1.1.1.3. General "The provisions of Chapter 4, General, shall apply." Chapter 4, Section 4.6.12.3, "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed." Section 4.6.12.4, "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. NFPA 13, "Installation of Sprinkler Systems." Chapter 26, Section 26.1, General, "A sprinkler system installed in accordance with this standard shall be properly inspected, tested and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed." NFPA 25, Chapter 14, Section 14.2 "Internal Inspection of Piping" "Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and be removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."

Findings Include:

The fire sprinkler system maintenance and inspection records was requested on August 06, 2019. There was no documentation to review that the 5 year internal obstruction had been completed within the last five years.

The COO and Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation to review that the 5 year internal obstruction had been completed within the last five years.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's." Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could potentially cause risk of harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1* "Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 "Horizontal sliding , Vertically Sliding, and Rolling Doors."
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

The annual fire rated door assembly records were requested on August 06, 2019. The facility did not have written records of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's for 2018.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation to review of the annual fire rated door assemblies for 2018.

This is a Condition Level Deficiency

Based on record review and interview with staff, it was determined the facility failed to develop and implement a maintenance program for the piped medical gas system. The facility failed to establish inspection and maintenance schedules through risk assessment and manufacturer recommendations increasing the potential for undetected problems with the medical gas delivery system. Failure to conduct a maintenance program and inspect the medical gas systems, control valves, alarms, gas outlets etc has potential to harm patients.

NFPA 99 2012 Health Care Facilities Section 5.1.14.2.2 Maintenance Programs. Section 5.1.14.2.2.2* "Inspection schedules. Scheduled inspections for equipment and procedures shall be established through risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction." A.5.14.2.2.2 "In addition: to the minimum inspection and testing in 5.1.14, facilities should consider annually inspections equipment and procedures and correcting any deficiencies." Section 5.1.14.2.2.3 "Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment." Section 5.1.14.4.4 Medical Gas an Vacuum Systems Maintenance and Record Keeping Section 5.1.14.4.1 "Permanent records of all tests required by 5.1.12.1 through 5.1.12.14 shall be maintained in the organizations files."

Findings include:

The facilities medical gas maintenance program documentation was requested on August 06, 2019. The facility did not have a documented medical gas maintenance program established.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that the facility did not have a documented medical gas maintenance program established.

This is a Condition Level Deficiency

Based on record review and interview with staff, it was determined the facility failed to have the required maintenance and inspection for the medical gas and vacuum piped systems. Failure to have annual inspections of the gas and vacuum piped systems has potential harm to patients during system failures.

NFPA 99 2012 Edition, Chapter 5, Section 5.2.13 "Category 2 Operation and Management. Category 2 systems shall comply with 5.1.14." Section 5.1.14.4.3 "An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity." Section 5.1.14.2.4 "Central supply systems for nonflammable gases shall conform to the following: (1) They shall be inspected annually; (2) They shall be maintained by a qualified representative of the equipment owner; (3) A record of the annual inspection shall be available for review by the authority having jurisdiction."

Findings Include:

The medical gas and vacuum piped systems inspection and maintenance records were requested on August 06, 2019. There was no documentation to review that the facility had their medical gas and vacuum piped system was inspected and maintained.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation to review that the facility had their medical gas and vacuum piped system was inspected and maintained.

Based on record review and interview with staff, it was determined that the facility failed to have a wet procedure location risk assessment for the procedure room. Failure to perform a risk assessment poses the potential risk to cause harm to the patient, if the facility does not identify areas where they are at risk related to electricity.

NFPA 99 2012 Edition, section 6.3.2.2.8.4* "Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise." Section 6.3.2.2.8.7* "Operating rooms defined as wet procedure locations shall be protected by either isolated power or ground-fault circuit interrupters."

Findings include:

The wet procedure location risk assessment documentation was requested on August 06, 2019. The GI Suite procedure room did not have isolated power or ground-fault circuit interrupters, and no risk assessment was conducted by the governing body.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no risk assessment conducted by the governing body.

This is a Condition Level Deficiency

Based on record review and interview with staff, it was determined that the facility failed to conduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility. Failing to test and document annually the receptacle testing of all patient care areas of the facility could lead to an ignition hazard in a patient care area, and potentially cause a fire and or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.1 "Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device." 6.3.4.1.2 "Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data." 6.3.4.1.3 "Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months."

Findings include:

The receptacle testing documentation was requested on August 06, 2019. There was no documentation available for review provided for receptacle testing in patient care areas for 2018.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation to review for receptacle testing in patient care areas for 2018.

Based on record review and interview with staff, it was determined the facility failed to document the required elements of the weekly visual inspection of the emergency generators. Failure to do weekly visual inspections of the emergency generators could result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 "Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year...Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly." NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes..."

Findings Include:

The emergency generator weekly visual inspection documentation was requested on August 06, 2019. The facility failed to document the required elements of the weekly visual inspection for the emergency generator according to NFPA 110. The facility only documented "Emergency Generator Heater" and associated temperature for 2018 and 2019.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that the facility failed to document the required elements of the weekly visual inspection for the emergency generator according to NFPA 110. The facility only documented "Emergency Generator Heater" and associated temperature for 2018 and 2019.

Based on observation and staff interview, it was determined the facility failed to ensure that appliances are directly plugged into wall outlet receptacles and not power strips. The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire has potential harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 "The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code." Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Findings include:

Observation on tour conducted on August 06, 2019, revealed the following items plugged into a power strip and not directly plugged in to the receptacle wall outlets:

1. Social Services, a refridgerator plugged into a power strip.
2. UR Director, a refridgerator plugged into a power strip.
3. Nurses station med room, in MedSurge, a refridgerator plugged into a power strip and a power strip into a power strip.
4. Physician sleeping room, a refridgerator plugged into a power strip.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that the above items were plugged into a power strip and not directly plugged in to the receptacle wall outlets.

Based on record review and interview with staff, it was determined the facility failed to have documented fire loss prevention in operating rooms. Failure to establish procedures for operating room emergencies and complete periodic evaluations made of hazards that could be encountered during surgical procedures, poses a potential risk for patient injury or possible death.

NFPA 99 2012 Edition, Section 15.13 Fire Loss Prevention in Operating Rooms. Section 15.13.1.1 "An evaluation shall be made of hazards that could be encountered during surgical procedures." Section 15.13.1.2 "The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment." Section 15.13.3.8 "Health care organizations shall establish policies and procedures outlining safety precautions related to the use of flammable liquid or aerosol germicides or antiseptics used in anesthetizing locations, as required in 15.14.1, whenever the use of electrosurgery, cautery, or a laser is contemplated." Section 15.13.3.9.1 "Procedures for operating room/surgical suite emergencies shall be developed." Section 15.13.3.9.2 "Procedures shall include alarm actuation, evacuation, and equipment shutdown procedures and provisions for control of emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department." Section 15.13.3.10.1 "New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use."

Findings include:

The fire loss prevention policy and procedure and the training records for this policy was requested on August 06, 2019. No documentation was available to review while onsite during the survey pertaining to fire loss prevention in operating rooms.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation available to review while onsite during the survey pertaining to fire loss prevention in operating rooms.