HospitalInspections.org

REMAINS AS CITED

Based on documentation review, observation and staff interview it was determined this facility failed to meet the requirements for sprinkler coverage for the construction type according to the National Fire Protection Association, Chapter 19.1.6.2. The facility census was nine at the time of the survey.

Findings include:

Tour of building 1 took place on 08/04/10 with staff C and G. Interview on 08/03/10, with staff C revealed the one story main building with basement was originally constructed in 1950 and since then has underwent multiple renovations and additions beginning in 1958 and extending through 1993.

Staff F acknowledged these findings on 08/03/10 at 1:00 PM, and stated there had been no changes in construction in the outer walls, inner load bearing walls, flooring, or roof structure since 05/14/10. This employee stated additional information was submitted to CMS on 08/02/10 as requested by CMS for review of construction type. Copies of this documentation were provided to the surveyor onsite at that time.

The findings identified during the 05/10/10-05/14/10 LSC survey remain as cited at the 08/03/10 Remaining Conditions of Participation Survey. See below:

Review of the occupancy permit during the 05/10/10-05/14/10, survey for the 1993 addition listed the construction as Type 2A and 2B.

After observation of the outer walls, inner load bearing walls, flooring and roof structure, during the 05/10/10-05/14/10 Life Safety Code (LSC) survey, a determination of Type II(111) was made. The inner columns were drywall protected and the roof girders were sprayed with fire retardant material.
No documentation was available for the original building and all subsequent additions.

Observation conducted by the LSC Surveyor during the 05/10/10-05/14/10 survey, of the outer walls, inner load bearing walls, flooring and roof structure a determination of Type II(000) was made. This concrete and steel structure was observed to be unprotected in most areas including the steel beams supporting the first floor and the steel girders supporting the roof. There was a two hour fire rated constructed wall separating most of the 1993 addition from the rest of the facility. A portion of the 1993 addition surrounding the courtyard was not updated with a suppression system as the rest of the addition was. This area was located on the opposite side of the two hour fire rated constructed wall. This entire area of this building lacked the required suppression system with the exception of two small areas of which one area was the laboratory.

During the 05/10/10-05/14/10 tour, additional visual verification by the LSC surveyor was made with staff BB on 05/14/10 at 8:45 AM to 9:00 AM. Tour of the old boiler room in the basement revealed unprotected steel beams supporting the cement first floor.

On the first floor and above the ceiling tile of the west corridor side of the gift shop, observation reveals unprotected steel girders supporting the roof.

The above findings were reviewed with staff BB on 05/14/10 at 9:05 AM. and he/she stated understanding, but held out hope for another solution than having to be sprinklered.

NEW CITATION

Based on observations and staff interviews, the facility failed to ensure doors protecting corridor openings were constructed to close in order to resist the passage of smoke as required by the code. This affected 11 of 25 sampled patient room corridor doors (Rooms 15,16,18, 21, 34, 49, 50, 52, 54, 56, and 58).

Findings include:

A tour was conducted in the facility on 08/04/10 between 8:30 AM and 4:00 PM., with Staff F and G. During the tour, the following patient room corridor doors were observed with positive latching hardware which failed to latch into the frame:
In the medical/surgical smoke compartment rooms 15, 16, 18, 21, 34 and in the maternity unit smoke compartment rooms 49, 50, 52, 54, 56 and 58.

The failure of these doors to latch securely was verified by Staff F during the tour. Staff F stated there is no preventative maintenance system in place to check these doors on a routine basis.

REMAINS AS CITED

Based on observation during tour and staff verification it was determined this hospital failed to ensure that all exit accesses were arranged to provide a safe transition from the building to a paved public way for all peoples utilizing this hospital and failed to ensure two (2) of eighteen doors sampled on the medical surgical unit released with not more than one releasing operation, as required by the code at 19.2.2.2.1 and 7.2.1.5.4. The total patient census at the time of the survey was 9.

Findings include:

During this survey on 08/04/10 between 8:30 AM and 4:00 PM a tour was conducted with Staff F and G. Observation was made of three exit discharges which did not provide safe travel to a paved public way from the building. These areas are:
1) On the south side of the MRI department, outside of the exit access, observation was made of an approximate nine by six foot cement stoop surrounded by grass. There was approximately 108 feet of grass between the cement stoop to the nearest paved public way.

2) On the north side of the MRI department, outside of the exit access, observation was made of an approximate four by twenty foot cement ramp that ended in the grass. There was approximately 170 feet of grass between the end of the cement ramp to the nearest paved public way.

3) Just outside the west exit access from the maternity department, observation was made of of an approximate six by twenty-one foot cement ramp that ended in the grass. There was approximately 96 feet of grass between the end of the cement ramp to the nearest paved public way.

These findings were observed and verified by staff F and staff G during the tour on 08/04/10. Staff F stated there were no changes made to these exit discharges since identified as non compliance with the LSC requirements during the Life Safety Code survey conducted 05/10/10-05/14/10.

During a tour on 08/04/10 with Staff F and G, two patient room doors were observed with a deadbolt lock located approximately 18 inches above the door handle. Interview at that time with Staff F revealed these deadbolt locks could be locked/unlocked only by using a key. This employee stated these rooms had been used as offices in the past and the deadbolt locks had not been removed The code at 7.2.1.5.4 requires doors to release with not more than one releasing operation.

NEW CITATION

Based on staff interviews and observations, the hospital failed to ensure eight of 20 exit discharges were equipped with lighting fixtures that would continue to illuminate the discharge areas in the event that a single bulb would fail during darkness, in accordance with the code at 7.8 and 19.2.8. This could affect all patients, staff and visitors in this hospital. The census at the time of the survey was 9.

Findings include:

A tour was conducted on 08/04/10 between 8:30 AM and 4:00 PM with Staff F and G. The following exit discharges were observed with a single light fixture that contained one bulb:

*On the south side of the MRI/diagnostics connector hallway (this single bulb light fixture was verified by Staff F as being burned out),

*Outside the Same Day Surgery area near the medical gas storage room and and outside the stairwell exit discharge in the surgical back hallway,

*Outside the west exit from the maternity department.

*Outside the exit discharge by rooms 34 and 36 on the medical surgical unit,

*Along approximately 25 feet of sidewalk behind the Intensive Care unit (no lighting fixture was observed to illuminate the sidewalk leading to the public way),

*Outside the Outpatient department, and

*Outside the Women's Health Department where the sidewalk/ramp leads to the public way.

These single bulb light fixtures were verified by the Staff F who accompanied the surveyor on tour.

NEW CITATION

Based on observations, staff interview and facility maintenance logs, the hospital failed to ensure anesthetizing locations (3 operating rooms) were protected in accordance with NFPA 99, 4.3.1.2.3 (n) and 5.4.1.1 in regard to maintaining relative humidity equal to or greater than 35%. The census at the time of the survey was nine.

Findings include:

An interview conducted with Staff F and C on 08/04/10 at 11:15 AM, revealed the hospital uses general anesthesia during surgery of patients. A tour of the three operating rooms (ORs) on 02:45 PM on 08/03/10 and on 08/04/10 between 11:20 AM and 11:30 AM, revealed the hospital has piped-in oxygen in these OR rooms. Individual temperature/humidity gauges were observed in each of the operating rooms.

A review of humidity logs for these ORs between January 2010 and August 2nd, 2010, revealed humidity levels were documented below 35 % for all three ORs on 01/29/10, (33-34%). Six days in February 2010 (02/1/10, 02/5/10, 02/10/10, 02/11/10, 02/16/10, and 02/17/10) humidity levels were documented as less than 35% for ORs #2 and #3. Humidity levels for these dates were between 32% and 34%. OR #2's humidity level was documented as 22% on 04/08/10 and on 05/10/10, as 21%. Documentation indicated maintenance was notified on both of these dates; however, there was no documentation of a re-check of the humidity on 04/08/10. A recheck of the humidity level on 05/10/10, after maintenance was notified, was documented as 33%.

An interview conducted with Staff C on 08/04/10 at 11:15 AM, revealed the standard hospital practice is for humidity levels to remain between 30-60%. An interview conducted with Staff J on 08/05/10 at 1:00 PM, verified the hospital policy is to maintain humidity levels in the ORs between 30-60%. Staff J verified no actions were taken to adjust the lower humidity levels for the aforementioned dates when the humidity level was less than 35%.

NEW CITATION

Based on observations, staff interview, and sprinkler inspection reports, the facility failed to inspect the sprinkler system in accordance with NFPA 13 in accordance with the NFPA 101, 2000 code section 39.1.5.2 and 6.2. This affected all staff and patients in the outpatient therapy facility. The census at the time of the survey was nine.


On 08/03/10, a review was conducted of the sprinkler inspection reports for this outpatient therapy facility. This last time this facility's sprinkler inspection was conducted was on 05/06/09. This sprinkler inspection report contained written violations which documented the sprinkler system control valves are not secured with tamper devices (electronic devices) or with a lock and chain. This was verified with Staff F and G on 08/04/10 at 3:45 PM. A tour of the facility on 08/05/10, with Staff I verified the facility has a complete automatic sprinkler system.

NEW CITATION

Based on observations and staff interview, the hospital failed to ensure one non sprinklered area of the hospital did not contain alcohol based hand rub (ABHR) containers directly over carpet. This involved the outpatient clinic and five ABHR containers of 1 liter sizes. This could affect all patients, staff and visitors in this area. The census at the time of the survey was nine.

Findings include:

A tour was conducted on 08/04/10 at 3:30 PM with Staff F and G. The outpatient clinic area was observed with carpeting throughout the waiting room and examination area. Five one-liter containers of ABHRs were observed hanging on the walls directly over carpeting. There were no sprinkler heads observed in this area.

An interview with Staff F during the tour verified the lack of sprinkler heads in this area of the building and verified the ABHR containers were hanging over carpeted floors.