HospitalInspections.org

Based on observations and interview, the facility failed to maintain the interior finish for the boiler room ceiling and also for the generator room wall for the past year. This practice affected no patients directly due to fire separation but had the potential to affect patients in the nearby vicinity if a fire were to get in the common spaces and spread. Facility census was 13 patients on date of survey, 9-20-10.

Findings are:

Observations on 9-20-10 at 4:30PM revealed a large (approximately 2.5 foot diameter) hole in the boiler room ceiling - likely where an old vent went through the ceiling.

During an interview on 9-20-10 at 4:30PM, the facility maintenance supervisor stated that he suspected the hole had been there for many years. He and I agreed that it was surprising to miss a hole like that since we had noted many other holes in the boiler room that needed sealed in past state inspections. The maintenance supervisor stated that the large hole in the ceiling and a much smaller one in the generator room would be properly patched as soon as possible to meet code provisions.

Review of NFPA 101, LSC 19.3.3.2 found that
Existing Interior Finish must meet a Class A or Class B fire rating with no holes or penetrations to reduce the potential of fire spread.

Based on observations and interview, the facility failed to maintain emergency exits in a manner that makes them available for full and instant use in the event of an emergency for two of three emergency exits that lead directly outside (20's wing and 40's wing). This practice affected all patients. Facility census was 13 patients on date of survey, 9-20-10.

Findings are:

Observations on 9-20-10 at 3:25PM revealed two emergency exits that lead directly outside are only able to be opened after entering a code and there is no code posted. This is in violation of Life Safety Code 19.2.2.2.4 as noted in Nebraska State Fire Marshal Official Interpretation 07-02. It should be noted that the doors do however open upon activation of the building's fire alarm system or in the event of electrical power loss. For guest and patient safety, the code must be posted in approved manner as referenced in the aforementioned interpretation (which was given to the facility). The doors are not equipped with a delayed egress feature.

During an interview on 9-20-10 at 3:25PM, the facility maintenance supervisor stated that he was unaware of these specific requirements and the doors do certainly open when the fire alarm goes off. He stated that the facility would comply with the regulations and choose a method for posting the code that would satisfy the code requirements and the needs of the facility. The maintenance supervisor surmised that all staff will likely post the code on their name badges so it is not forgotten in a panicked situation.

Record review of Nebraska State Fire Marshal Official Interpretation 07-02 found that special door locking arrangements are acceptable provided the following criteria are met:
(1). The card to operate the electronic lock is available to all staff, visitors and patients that do not require specialized security measures for their safety. Card readers are permitted when all staff
members carry the card to operate the card reader device.
(2). The code to release the electronic lock is available to all staff, visitors and patients that do not require specialized security measures for their safety. The code for releasing electronic locked doors must be posted. The code may be posted at the reception desk or on the wall adjacent to the code reader release device on either side of the locked door.

Based on observations and staff interview, the facility failed to maintain exit light illumination for two exit signs in the E.R. and Radiology areas. This practice affected all persons who might need to use these emergency exit. There are no patient rooms in this area but the E.R. has several beds and there are typically five to twenty people in these areas. Facility census was 13 residents on date of survey, 9-20-10.

Findings are:

Observations on 9-20-10 at 3:45PM revealed that the bulbs in the exit sign for the aforementioned areas were burnt out.

During an interview on 9-20-10 at 3:45PM, the facility maintenance man stated that he is frequently changing exit sign light bulbs and that he would get these bulbs changed as soon as possible. He also hinted that the facility may just replace those units with newer models with the LED bulbs.

Review of NFPA 101, LSC 7.10.5.1 revealed that all exit signs must be continuously illuminated to show occupants where to escape in the event of a fire or other emergency.

Based on observations and staff interview, the facility failed to have the proper electrical equipment for the nurses station that leads to the "20's and 40's" wings which house patient rooms. This practice affected all patients and staff. Facility census was 13 patients on 9-20-10.

Findings are:

Observations on 9-20-10 at 3:15PM revealed a disapproved multi-outlet power tap (surge strip) in use at the nurses station which is also open to the corridors.
Disapproved surge strips that are not medical grade and UL listed are a potential fire hazard as per Nebraska State Fire Marshal Official Interpretation 08-01. The UL listing must have numbers 60601-01 or 60950-1 to be approved as medical grade. This interpretation was given to the facility maintenance supervisor, along with approved power taps that are available to them.
During an interview on 9-20-10 at 3:15PM, the facility maintenance supervisor stated that he was not aware of the power tap or surge strip regulation. The maintenance supervisor stated that there may be other power taps like the one found at the nurses station in other parts of the facility (that are open to the corridor or general patient care areas) and that if they are indeed of the disapproved variety, he shall replace them with approved devices.

Review of Nebraska State Fire Marshal Official Interpretation 08-01 revealed that the facility shall not use unapproved power taps to decrease the risk of fire. Only approved relocatable power taps (or 'surge strips') shall be used because they have been UL tested and proven to be safer than the devices that have not met the medical grade standards.

Based on observations and interview, the facility failed to maintain the interior finish for the boiler room ceiling and also for the generator room wall for the past year. This practice affected no patients directly due to fire separation but had the potential to affect patients in the nearby vicinity if a fire were to get in the common spaces and spread. Facility census was 13 patients on date of survey, 9-20-10.

Findings are:

Observations on 9-20-10 at 4:30PM revealed a large (approximately 2.5 foot diameter) hole in the boiler room ceiling - likely where an old vent went through the ceiling.

During an interview on 9-20-10 at 4:30PM, the facility maintenance supervisor stated that he suspected the hole had been there for many years. He and I agreed that it was surprising to miss a hole like that since we had noted many other holes in the boiler room that needed sealed in past state inspections. The maintenance supervisor stated that the large hole in the ceiling and a much smaller one in the generator room would be properly patched as soon as possible to meet code provisions.

Review of NFPA 101, LSC 19.3.3.2 found that
Existing Interior Finish must meet a Class A or Class B fire rating with no holes or penetrations to reduce the potential of fire spread.

Based on observations and interview, the facility failed to maintain emergency exits in a manner that makes them available for full and instant use in the event of an emergency for two of three emergency exits that lead directly outside (20's wing and 40's wing). This practice affected all patients. Facility census was 13 patients on date of survey, 9-20-10.

Findings are:

Observations on 9-20-10 at 3:25PM revealed two emergency exits that lead directly outside are only able to be opened after entering a code and there is no code posted. This is in violation of Life Safety Code 19.2.2.2.4 as noted in Nebraska State Fire Marshal Official Interpretation 07-02. It should be noted that the doors do however open upon activation of the building's fire alarm system or in the event of electrical power loss. For guest and patient safety, the code must be posted in approved manner as referenced in the aforementioned interpretation (which was given to the facility). The doors are not equipped with a delayed egress feature.

During an interview on 9-20-10 at 3:25PM, the facility maintenance supervisor stated that he was unaware of these specific requirements and the doors do certainly open when the fire alarm goes off. He stated that the facility would comply with the regulations and choose a method for posting the code that would satisfy the code requirements and the needs of the facility. The maintenance supervisor surmised that all staff will likely post the code on their name badges so it is not forgotten in a panicked situation.

Record review of Nebraska State Fire Marshal Official Interpretation 07-02 found that special door locking arrangements are acceptable provided the following criteria are met:
(1). The card to operate the electronic lock is available to all staff, visitors and patients that do not require specialized security measures for their safety. Card readers are permitted when all staff
members carry the card to operate the card reader device.
(2). The code to release the electronic lock is available to all staff, visitors and patients that do not require specialized security measures for their safety. The code for releasing electronic locked doors must be posted. The code may be posted at the reception desk or on the wall adjacent to the code reader release device on either side of the locked door.

Based on observations and staff interview, the facility failed to maintain exit light illumination for two exit signs in the E.R. and Radiology areas. This practice affected all persons who might need to use these emergency exit. There are no patient rooms in this area but the E.R. has several beds and there are typically five to twenty people in these areas. Facility census was 13 residents on date of survey, 9-20-10.

Findings are:

Observations on 9-20-10 at 3:45PM revealed that the bulbs in the exit sign for the aforementioned areas were burnt out.

During an interview on 9-20-10 at 3:45PM, the facility maintenance man stated that he is frequently changing exit sign light bulbs and that he would get these bulbs changed as soon as possible. He also hinted that the facility may just replace those units with newer models with the LED bulbs.

Review of NFPA 101, LSC 7.10.5.1 revealed that all exit signs must be continuously illuminated to show occupants where to escape in the event of a fire or other emergency.

Based on observations and staff interview, the facility failed to have the proper electrical equipment for the nurses station that leads to the "20's and 40's" wings which house patient rooms. This practice affected all patients and staff. Facility census was 13 patients on 9-20-10.

Findings are:

Observations on 9-20-10 at 3:15PM revealed a disapproved multi-outlet power tap (surge strip) in use at the nurses station which is also open to the corridors.
Disapproved surge strips that are not medical grade and UL listed are a potential fire hazard as per Nebraska State Fire Marshal Official Interpretation 08-01. The UL listing must have numbers 60601-01 or 60950-1 to be approved as medical grade. This interpretation was given to the facility maintenance supervisor, along with approved power taps that are available to them.
During an interview on 9-20-10 at 3:15PM, the facility maintenance supervisor stated that he was not aware of the power tap or surge strip regulation. The maintenance supervisor stated that there may be other power taps like the one found at the nurses station in other parts of the facility (that are open to the corridor or general patient care areas) and that if they are indeed of the disapproved variety, he shall replace them with approved devices.

Review of Nebraska State Fire Marshal Official Interpretation 08-01 revealed that the facility shall not use unapproved power taps to decrease the risk of fire. Only approved relocatable power taps (or 'surge strips') shall be used because they have been UL tested and proven to be safer than the devices that have not met the medical grade standards.