HospitalInspections.org

Based on observation it was determined the facility failed to fill penetrations in four smoke barriers for the facility.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose...."

Finding s include:

On August 11, 2016 the surveyor, accompanied by the Senior Lead Maintenance Tech observed unsealed penetrations in four smoke barriers located at or by the following areas of the facility.

1. Acute Care
2. Human Resources office
3. Room 114
4. Information systems

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients.

Based on observation it was determined the facility did not keep exits readily accessible at all times and reduced the corridor width from eight feet in width with medical equipment stored in wooden crates in the exit corridors.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7." Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width." Chapter 7 Section 7.5.1.1 " Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel...."

Findings include:

On August 11, 2016 the surveyor, accompanied by the Senior Lead Maintenance Tech observed storage Bio medical equipment in boxes on a wooden pallet crate by the employee entrance exit corridor to include two bed gurneys. The storage was blocking the exit access and reduced the exit corridor width from eight feet in width to 5 1/2 feet which also included the operating room West hallway with medical equipment on wooden pallets stored in the exit access corridor.

During the exit conference on August 11, 2016, the above findings were again acknowledged by the Chief Executive Officer Lead Maintenance Tech.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation and record review with the Senior Lead Maintenance Tech the facility failed to test and document the Monthly thirty second test for two months, and conduct the Annual 90 minute 1/1/2 hour test of three battery back up emergency lighting units located on the second floor Business office.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9." Section 7.9.3 Periodic Testing of Emergency Lighting Equipment: "...A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction...."

Findings include:

On August 11, 2016 the surveyor accompanied by the Senior Lead Maintenance Tech reviewed the battery backup emergency lighting documentation. The documentation did not include a thirty second Monthly test was completed for June and July of 2016, and there was 90 minute 1/1/2 hour test completed for 2015 for the battery backup emergency lights in the Business office corridor.

During the exit conference on August 11, 2016, the above findings were again acknowledged by the Chief Executive Officer Lead Maintenance Tech.

Failing to test document the emergency lighting units Monthly and Annually could cause harm to the staff and patients.

Based on observation it was determined that the facility did not assure that the ABC, K and Halon type fire extinguisher were readily available for use in case of a fire.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1." Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers."

NFPA 10, Chapter 1, General Requirements, Section 1-6.3 "Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of a fire."

Findings include:

On August 11, 2016 the surveyor, accompanied by the Senior lead Maintenance Tech observed the following ABC, K and Halon type fire extinguishers located in the following areas were blocked by equipment and not readily available for use in an emergency.

1. Employee entrance corridor blocked by a gurney bed.
2. X ray room Halon fire extinguisher blocked by medical equipment.
3. K fire extinguisher in the kitchen blocked by a paper shredder

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failing to make a fire extinguisher readily available in case of a fire will cause injury to patients in time of a fire.

Based on observation, it was determined that the facility failed to clean four of four kitchen exhaust hood system baffle filters, and the grease drip tray more than once a month.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19-3.2.6, "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge."

Findings include:

On August 11, 2016 the surveyor, accompanied by the Senior lead Maintenance Tech and two kitchen staff members inspected the kitchen exhaust system hood, four of four baffle filters had an excessive amount of grease buildup on the filters.

The kitchen staff advised the surveyor the cleaning was done only once a month and the computer log shown to the surveyor on the hood cleaning had verified it was cleaned July 16 and due August 15, 2016 only once a month.

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on record review and interview with the Senior Lead Maintenance Tech it was determined the kitchen hood was not cleaned semi-annually in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "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 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually" Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3." Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.6, "Cooking facilities shall be protected in accordance with 9.2.3". Section 9.2.3, "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations".NFPA 96, Chapter 8, Section 8-2." An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons."

Findings include:

On August 11, 2016 the surveyor accompanied by the Senior Lead Maintenance Tech reviewed the February 2016 documentation for the kitchen hood fire extinguishing system and exhaust hood.

The Maintenance Director was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96 semi-annually in all of 2015.

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failure to inspect, test, and maintain the kitchen hood fire protection system will result in harm to the patients through delayed detection and extinguishment of a fire.

Based on observation with the Senior Lead Maintenance Tech the facility allowed the use of multiple outlet adapters to be used for appliances.

NFPA 101, Life Safety Code, 2000, 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, " 1999 Edition. NFPA 99, Chapter 3, Section
3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) 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:

On August 11, 2016 the surveyor accompanied by the Senior Lead Maintenance Tech observed the use of multiple outlet adapters in use for appliances, a microwave and toaster oven was observed in use in the following locations in the facility.

1. Doctors sleep quarters, microwave and toaster.
2. Copy room 2nd floor microwaves into power strips.

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

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 could cause harm to the patients.

Based on observation it was determined the facility failed to fill penetrations in four smoke barriers for the facility.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose...."

Finding s include:

On August 11, 2016 the surveyor, accompanied by the Senior Lead Maintenance Tech observed unsealed penetrations in four smoke barriers located at or by the following areas of the facility.

1. Acute Care
2. Human Resources office
3. Room 114
4. Information systems

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients.

Based on observation it was determined the facility did not keep exits readily accessible at all times and reduced the corridor width from eight feet in width with medical equipment stored in wooden crates in the exit corridors.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7." Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width." Chapter 7 Section 7.5.1.1 " Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel...."

Findings include:

On August 11, 2016 the surveyor, accompanied by the Senior Lead Maintenance Tech observed storage Bio medical equipment in boxes on a wooden pallet crate by the employee entrance exit corridor to include two bed gurneys. The storage was blocking the exit access and reduced the exit corridor width from eight feet in width to 5 1/2 feet which also included the operating room West hallway with medical equipment on wooden pallets stored in the exit access corridor.

During the exit conference on August 11, 2016, the above findings were again acknowledged by the Chief Executive Officer Lead Maintenance Tech.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation and record review with the Senior Lead Maintenance Tech the facility failed to test and document the Monthly thirty second test for two months, and conduct the Annual 90 minute 1/1/2 hour test of three battery back up emergency lighting units located on the second floor Business office.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9." Section 7.9.3 Periodic Testing of Emergency Lighting Equipment: "...A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction...."

Findings include:

On August 11, 2016 the surveyor accompanied by the Senior Lead Maintenance Tech reviewed the battery backup emergency lighting documentation. The documentation did not include a thirty second Monthly test was completed for June and July of 2016, and there was 90 minute 1/1/2 hour test completed for 2015 for the battery backup emergency lights in the Business office corridor.

During the exit conference on August 11, 2016, the above findings were again acknowledged by the Chief Executive Officer Lead Maintenance Tech.

Failing to test document the emergency lighting units Monthly and Annually could cause harm to the staff and patients.

Based on observation it was determined that the facility did not assure that the ABC, K and Halon type fire extinguisher were readily available for use in case of a fire.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1." Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers."

NFPA 10, Chapter 1, General Requirements, Section 1-6.3 "Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of a fire."

Findings include:

On August 11, 2016 the surveyor, accompanied by the Senior lead Maintenance Tech observed the following ABC, K and Halon type fire extinguishers located in the following areas were blocked by equipment and not readily available for use in an emergency.

1. Employee entrance corridor blocked by a gurney bed.
2. X ray room Halon fire extinguisher blocked by medical equipment.
3. K fire extinguisher in the kitchen blocked by a paper shredder

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failing to make a fire extinguisher readily available in case of a fire will cause injury to patients in time of a fire.

Based on observation, it was determined that the facility failed to clean four of four kitchen exhaust hood system baffle filters, and the grease drip tray more than once a month.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19-3.2.6, "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge."

Findings include:

On August 11, 2016 the surveyor, accompanied by the Senior lead Maintenance Tech and two kitchen staff members inspected the kitchen exhaust system hood, four of four baffle filters had an excessive amount of grease buildup on the filters.

The kitchen staff advised the surveyor the cleaning was done only once a month and the computer log shown to the surveyor on the hood cleaning had verified it was cleaned July 16 and due August 15, 2016 only once a month.

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on record review and interview with the Senior Lead Maintenance Tech it was determined the kitchen hood was not cleaned semi-annually in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "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 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually" Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3." Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.6, "Cooking facilities shall be protected in accordance with 9.2.3". Section 9.2.3, "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations".NFPA 96, Chapter 8, Section 8-2." An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons."

Findings include:

On August 11, 2016 the surveyor accompanied by the Senior Lead Maintenance Tech reviewed the February 2016 documentation for the kitchen hood fire extinguishing system and exhaust hood.

The Maintenance Director was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96 semi-annually in all of 2015.

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

Failure to inspect, test, and maintain the kitchen hood fire protection system will result in harm to the patients through delayed detection and extinguishment of a fire.

Based on observation with the Senior Lead Maintenance Tech the facility allowed the use of multiple outlet adapters to be used for appliances.

NFPA 101, Life Safety Code, 2000, 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, " 1999 Edition. NFPA 99, Chapter 3, Section
3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) 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:

On August 11, 2016 the surveyor accompanied by the Senior Lead Maintenance Tech observed the use of multiple outlet adapters in use for appliances, a microwave and toaster oven was observed in use in the following locations in the facility.

1. Doctors sleep quarters, microwave and toaster.
2. Copy room 2nd floor microwaves into power strips.

During the exit conference on August 11, 2016 the above findings were again acknowledged by the Chief Executive Officer and Senior Lead Maintenance Tech.

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 could cause harm to the patients.