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Based on observation and staff interview it was determined the facility failed to ensure roller latches were not installed, faield to ensure there were no impediment to the closing of doors, and that doors are provided with a means suitable for keeping the door closed.

Findings:

On 10/18/2016 at 12:12 p.m., a roller latch was observed on the bathroom door of patient room 103.

At 12:15 p.m., a roller latch was observed on the dutch door in the staff breakroom across from patient room 103.

The physical plant director acknowledged the roller latches.

At 12:21 p.m., chocks were seen installed on the doors to ER #1 and ER #2.

The administrator acknowledged the doors chocks in use.

On 10/20/2016 at 9:00 a.m., the door leading out of the medical records office to patient rooms was hard to open, did not have positive latching hardware and did not have self-closing hardware. The second door leading out of the medical records office had a dead-bolt, no positive latching hardware.

Based on observation it was determined the facility failed to ensure doors in an exit passageway had self-closing hardware.

Findings:

On 10/18/2016 at 12:55 p.m., A dirty linen hazardous area room was observed to have the door open with no self-closing hardware.

On 10/19/2016 at 09:29 a.m., a clean linen storage room door had no self-closing hardware and was open to the corridor.

Based on observation and staff interview it was determined the facility failed to ensure smoke barriers were free of penetrations and protected.

Findings:

On 10/18/2016 at 12:55 p.m., one penetration was observed in the plenum space above the drop ceiling above patient room 101. The penetration was a hole where a clock had been installed then removed.

The director of plant operations acknowledged the penetration.

Based on observation it was determined the facility failed to ensure hazardous areas are protected.

Findings:

On 10/19/2016 at 09:15 a.m., it was observed a corridor door to a room labeled central storage and supply which contains supplies, including: Two 5 shelve steel racks filled with clean linen, 6 "E" cylinders of oxygen had no positive latching hardware.

Based on observation and staff interview the facility failed to provide patient room doors arranged so that patients can always open the door from inside without using a key.

Findings:

On 10/18/2016 at 12:21 p.m., dead-bolt locking devices were found on the doors to patient rooms 101 and 102.

At 12:22 p.m., the administrator was asked about the dead-bolt locks. She said when auditors are at the facility they use the dead-bolts to lock the contents within the room.

On 10/19/2016 at 09:45 a.m., a dead-bolt lock was observed to be on an egress exit door leading out of the infection control office.

Based on observation and staff interview it was determined that emergency generator powered lighting could not be confirmed throughout the facility.

Findings:

On 10/20/2016 at 14:00, during a tour of the facility emergency lighting in the facility corridors, exit accesses and exit discharge could not be identified or observed. The exit discharge near the cafeteria did not have emergency egress lighting to a public way.

The director of plant operations accompanying the LSC surveyors on tour was interviewed. He was asked what lights in the facility are powered by the generator. He said he knows some of the lights are on generator power but cannot identify them.

On 10/21/2016 the monthly and annual logs for inspection of battery powered emergency lighting were requested. On review of the documentation provided indicated weekly/monthly checks of battery powered emergency lighting but did not indicate if they were tested for 30 seconds a month and 90 minutes a year.

Based on record review it was determined the facility failed to ensure fire drills were held at unexpected times under varying conditions at least quarterly on each shift.

Findings:

On 10/18/2016 at 9:15 a.m., on record review of the facility's fire drills revealed only fire drills for 2015 and not for 2016 for each shift.

Based on record review it was determined the facility failed to ensure smoke detectors were inspected, maintained and tested in accordance with the manufactures specifications.

Findings:

On 10/21/2016 at 11:15 a.m., on review of Atomic Services fire alarm system inspection report dated 11-13-14 indicated smoke detectors, magnetic hold open devices, and pull stations were not inspected, maintained, or tested. No inspection report for 2015 or 2016 was provided. No smoke alarm sensitivity testing reposts were provided when requested.

Based on record review the facility failed to require automatic sprinkler systems be continuously maintained in reliable operating condition and be inspected and tested periodically.

Findings:

On 10/18/2016 at 13:37, on record review of the fire alarm sprinkler system inspection reports from Atomic Services dated 11-15-2015 revealed gauges, main drain, and alarm signaling devices connected to the facility fire alarm sprinkler system were not inspected, maintained or tested. The Atomic inspection report had those areas marked as "NA" on the 11-15-2015 inspection report.

Based on observation the facility failed to inspect, and maintain HVAC systems supply and mechanical exhaust vent fans.

Findings:

On 10/18/2016 at 11:30 a.m., Mechanical exhaust fans, including those in toilet rooms, were not observed to not be operating or functioning. Exhaust fan grills were observed to be covered in a furry brown material.

At 11:31 a.m., room 101 was identified as the facility isolation room by facility staff. On tour of the room it was observed to not be negatively ventilated. There was no HVAC system in the room. The room had an air conditioner unit installed in the window of the room. No devices/gauges were present to indicate if room 101 was negative or positive.

Based on observation and staff interview it was determined the facility failed to ensure loosely hanging fabrics were flame resistant.

Findings:

On 10/18/2016 at 12:27 p.m., a 10 foot by 6 foot curtain was observed hanging in ER #1 and its label did not indicate it was flame retardant.

Staff present at the time of the facility tour were interviewed and asked if the curtain is chemically treated to be flame resistant and asked for the documentation of the chemical treatments. The facility staff person said they have not treated the curtain.

Based on observation, record review and staff interview it was determined the facility failed to ensure their medical gas storage was protected, maintained and inspected as required.

Findings:

On 10/18/2016 at 12:56 p.m., the facility medical gas storage room door was observed to have no positive latching hardware, and no self-closer.

The director of plant operations acknowledged the missing self-closing and positive latching hardware.

At 12:28 p.m., a housekeeping cart, and two mist-tent biomed units were observed to be stored within the medical gas storage room.

At 12:59 p.m., two light switches, an emergency power red plug duplex electrical receptacle, and a single electrical power receptacle were observed to be installed less than 5 feet from the floor of the medical gas storage area.

The director of plant operations acknowledged the stored items and electrical items installed less than 5 feet from the floor in the medical gas storage room.

On 10/20/2016 at 10:07 a.m., the last three years (2016, 2015, 2014) of medical gas system inspection reports were requested and only the 2015 inspection report reviewed was from Airgas dated 6-22-2015, the 2016 and 2014 medical gas annual inspections were not provided.

The administrator advised they had called their vendor for them but they do not have the other medical gas system inspections.

The 2015 medical gas inspection report from Airgas dated 6-22-2015 indicated there was only one alarm on the medical gas system, no ground rod at the pad site/bulk gas vessel not grounded, and it is unknown if the medical gas system will automatically switch to the reserve supply bank if the bulk vessel becomes empty, vessel does not have a diverter assembly and does not have dual pressure relief devices (PRD's).

The surveyor asked the administrator if the recommendations outlined on the 6-22-2015 medical gas system inspection report were completed. She said no.

Based on observation and staff interview the facility failed to provide a Type 1 Essential Electrical system in accordance with NFPA 99.

Findings:

On 10/18/2016 at 11:33 a.m., while on tour of the facility no remote annunciator was observed. A remote annunciator, storage & battery powered, shall be provided to operate outside of the generator location area in a location continuously supervised by facility staff at a regular work station.

The director of plant operations said that they have not installed the remote annunciator that was cited on their last survey.

Based on observation it was determined the facility failed to ensure their medical gas warning system had two alarms in separate locations.

Findings:

On 10/18/2016 at 13:00, while on tour of the facility's medical gas system revealed there were not two master alarms in separate locations which had audible and visible signals.

Based on observation and staff interview it was determined the facility failed to ensure their medical gas storage area had precautionary signage.

Findings:

On 10/18/2016 at 12:56 p.m., the door to the medical gas storage reserve bank was observed to have no precautionary sign which was readable from a distance of 5 feet. An exit sign was observed to be on the medical gas storage room.

The operations plant director acknowledged their medical gas storage room had no signage.

Based on observation and staff interview it was determined the facility failed to ensure the Type I EES was divided into critical branch, and life safety branch electrical breaker panels.

Findings:

On 10/19/2016 at 11:14 a.m., it was observed the facility had several electrical panels in the facility. None of the electrical panels inspected were labeled life safety branch and/or critical branch. On inspection of the contents of the electrical panels throughout the facility it was observed the components of the LSC branch panel were mixed with the critical branch panel components. The life safety code and critical branch electrical individual breakers were not labeled/identified.

The director of plant operations acknowledged the life safety branch and critical branch could not be identified along with their specific components for each not being identified.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure protection of electrical wiring and equipment as required.

Findings:

On 10/18/2016 at 12:27 p.m., two power strips were observed to be in use within ER #1.

On 10/19/2016 at 09:35 a.m., patient room 116 was observed to have a microwave and refrigerator plugged into a power tap.

At 09:44 a.m., a daisy chained extension cord was observed to be plugged into a power tap connected to a desktop computer which was located in the infection control office.

At 09:56 a.m., patient room 117 had a refrigerator plugged into a power tap.

At 10:46 a.m., while on tour of the building housing the CT system revealed no emergency powered electrical receptacles could be identified. There were two normal power electrical receptacles observed in the room. A power tap was observed to be in use in the CT office. The CT device was contained within a fabricated building which was built in 2008.

At 10:47 a.m., the CT assistant was asked if emergency room patients are ever brought to the CT area. He said yes.

At 10:55 a.m., two blood bank refrigerators located in the laboratory were plugged into a power tap.

On 10/20/2016 at 11:15 a.m., two multiplug's were observed to be in use in the administrative offices of the facility.

Based on observation it was determined the facility failed to ensure alcohol based hand rub dispenser(s) (ABHR) were not installed over an ignition source(s).

Findings:

On 10/18/2016 at 13:01, an ABHR was observed to be installed over an ignition source across from the drug room.

On 10/19/2016 at 15:19, one ABHR in the laboratory was observed to be installed over an electrical light switch.

The physical operations director acknowledged the ABHR dispensers installed over ignition sources in the laboratory.