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Based on observations, the facility failed to assure that hazardous areas are enclosed as required. Section 8-2.3.2.1(a) requires door assemblies to be of an approved type installed in accordance with NFPA 80. Section 8-2.3.2.1(b) requires every fire door to be self-closing. NFPA 80, Section 2-1.4.1 requires self-closing doors to swing easily and freely and to be equipped with a closing device to cause the door to close and latch each time it is opened. The closing mechanism shall not have a hold-open feature.

THE FINDINGS INCLUDE:

- Observations while touring the facility on May 19, 2011 revealed that the corridor (36" active leaf) door to the basement level Administration Building storage room, known as Area 51 (approximately 35' x 45' = 1575 sq. ft.) was prevented from closing by the storage of a pallet jack in the path of the door's swing. This area opens to the basement level egress corridor. The pallet jack was noted impeding the door's path of closure at 10:20 AM and 12:35 PM, no facility staff were noted in the area at these times. By 4:30 PM on May 19, 2011, the pallet jack was noted to be properly stored so when the corridor door was released from it's hold open device each door leaf(s) operated properly.

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on observations, the facility failed to assure that stairwells are enclosed as required. NFPA 80, Section 2.1.4.1 requires self-closing doors to swing easily and freely and to be equipped with a closing device to cause the door to close and latch each time it is opened. Section 2.4.1.2 requires a closing device to be installed on every fire door. Section 2.4.1.4 requires all closing mechanisms to be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of May 19, 2011 revealed that the West Building's 2nd floor level south stair door does not close and latch when released from the open position. The door was released four (4) times from the open position with the latch mechanism failing to overcome the resistance at the strike plate each time.

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on observations, the facility failed to ensure that doors in the path of egress are in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.2.1.5.1 requires doors to be arranged to be opened readily from the egress side whenever the building is occupied. Section No. 7.7.3 states that the exit discharge be arranged and marked to make clear the the direction of egress to the public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

THE FINDINGS INCLUDE:

Observations while touring the facility during the morning of May 19, 2011:

1. The Center Building north stair proceeds one story (to the basement level) below the level of exit discharge (1st floor level). No interrupting measures were provided to prevent travel beyond the level of exit discharge.

2. The West Building south stair proceeds one story (to the basement level Kitchen) below the level of exit discharge. No interrupting measures were provided to prevent travel beyond the level of exit discharge.


This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on observations and confirmed by staff, the hospital failed to properly maintain the 2-hour fire wall between the buildings. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

Observations while touring the facility during the morning and afternoon hours of May 19, 2011 revealed that the basement level barrier door between the Center Building and the Administration Building does not latch in its door frame when released from the open position. Observations while touring the facility during the morning and afternoon hours of May 20, 2011 revealed the following:

- The second floor level barrier door in the West Building's Mechanical Room to the roof access corridor is not equipped with a door closing device.

-The West Building's first floor level barrier wall above the cross-corridor doors, adjacent to Central supply, has a 2" x 6" unsealed void around Electrical metal tubing (EMT). The void was filled with fire rated caulking by facility staff after the surveyor indicated the deficient practice.

-The Center Building's first floor level barrier wall above the in-lay ceiling tiles in the Scheduling Office / Conference Room has a 5" x 7" unsealed void around Electrical metal tubing (EMT). The void was filled with fire rated caulking and gypsum wallboard (GWB) by facility staff after the surveyor indicated the deficient practice.

-The Center Building's first floor level barrier wall above the cross-corridor doors, adjacent to room #111, has two unsealed void around electrical wiring and data wire. The voids were filled with fire rated caulking by facility staff after the surveyor indicated the deficient practice.

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on record review and confirmed by staff interview, the facility failed to ensure that battery powered emergency lights are maintained and tested as required. Section 7.9.3 requires a functional test to be conducted at 30-day intervals for not less than 30 seconds and an annual test for not less than 1-1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

THE FINDINGS INCLUDE:

- Record review on the morning of May 20, 2011 revealed that the battery powered emergency lights were not tested in January 2011 and September 2010.

This was confirmed by the Director of Plant Operations.

Based on record review and confirmed by staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

The facility failed to conduct quarterly fire drills during the second, third, and fourth quarters of 2010.

During an interview on the morning of May 20, 2011, the facility's Director of Plant Operations stated the following: "As I told the other LSC surveyor, I can not find any fire drills for the last three quarters of (2010) last year. I have fire drills for the first quarter of 2011 and the first quarter of 2010. I can not find them and I can not make them up."

Documentation provided indicates that fire drills were conducted on:
- March 30, 2011, at 9:42 PM (7PM-7AM shift);
- March 30, 2011, at 11:36 AM (7AM -7PM shift);
- March 26, 2011, at 12:26 PM (7AM -7PM shift);
- March 29, 2010, at 5:55 PM ; and
- March 26, 2010, at 11:33 AM.

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on record review and confirmed by interview with the Director of Plant Operations, the facility failed to ensure that a 30 minute discharge test is performed on the fire alarm system backup batteries annually. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

- Record review of the quarterly fire alarm system inspection reports available on May 18, 2011, revealed that the vender contracted to maintain, test and inspect the fire alarm system failed to provide detailed information as to the results of the tests and inspections as required by NFPA 72 as follows:
Since the batteries were replaced on January 14, 2010 it is not documented on the inspection reports dated April 1, 2010, July 19, 2010, October 22, 2010, January 18, 2011, and April 18, 2011, that the 30 minute discharge test was performed.
This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings

Based on observation, the facility failed to provide a complete automatic sprinkler protection system to cover all areas of the building. NFPA 13, Section 5.1.1(1) requires sprinklers to be installed throughout the premises. Section 5-13.7 requires sprinklers to be installed in spaces under all combustible ground floors, exterior docks, and platforms.

THE FINDINGS INCLUDE:

During the morning hours of May 18, 2011, it was noted that:

The automatic sprinkler system is not provided in the following areas:

1. The basement level, Clean Linen Storage Room closet. (Initially installed as a future narcotics closet when pharmacy planned to occupy space now know as the Clean Linen Storage Room.)

2. The three (3) kitchen walk-in refrigerators and freezers.

3. The third floor level, Steris Cleaning Room is not equipped with complete automatic sprinkler system.

Automatic sprinkler system is not provided under the west exterior (22.5 ft. x 145 ft.) overhang where 10 parking spaces and an ambulance entrance is provided. Throughout the morning and afternoon hours of May 19, 2011, and May 20, 2011 six to eight cars were parked under the overhang.

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on record review, the facility failed to ensure that the automatic sprinkler system is maintained and inspected as required by NFPA #25. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years. The facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

- Record review of the quarterly automatic sprinkler system records available on May 25, 2011 revealed that there is no record of the alarm valve having been inspected internally in the past 5 years.

- Observations while touring the facility on the morning of May 25, 2011 revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored.

Pressure gauges are installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventer.

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on observation and confirmed by the Director of Plant Operations , the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA #90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

- Record review of the facilities fire damper maintenance logs on the morning of May 20, 2011 revealed that fire dampers were last serviced during 1985.

This was confirmed by the Director of Plant Operations.

Based on observations, the facility failed to ensure that corridors are kept free of all obstructions and impediments.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the mornings of May 20, 2011 and May 23, 2011 revealed that corridors throughout the facility are cluttered by equipment such as: laundry carts, linen carts, scales, medical supply carts, housekeeping carts, thereby infringing on the full instant use of corridors as well as obstructing access to exits.
- Bath-in-a-Bag heating cabinets are plugged into corridor wall mounted electrical receptacles at room #219, #225, #104, and #110.
- A workstation-on-wheels (WOW) is plugged into a corridor wall mounted electrical receptacle at the 2-west nurses station.
- A patient scale, a clean linen cart and a blood pressure cuff plugged into the corridor wall mounted electrical receptacle, are stored adjacent to room #109 in front of the center - north stair door, reducing the corridor in front of the door to 24" wide.

This was confirmed by the Director of Plant Operations.

Surveyor: Stanton, Mark
Based on observations, record review and confirmed by staff, the facility failed to inspect and maintain the medical gas systems as required. NFPA 99, Section 4.3.1.1.2(a)(10)(b) and NFPA #50, Section 4.2.1 require each bulk oxygen system installed on consumer premises to be inspected annually and maintained by a qualified representative of the equipment owner. NFPA 101, Section 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 101, Section 4.3.5.6.1 Patient Vacuum Systems.(a) Maintenance. The facility shall establish routine preventive maintenance programs applicable to both the vacuum piping system and to the secondary equipment attached to vacuum station inlets to ensure the continued good performance of the entire vacuum system.

THE FINDINGS INCLUDE:

1. While reviewing the bulk oxygen records on morning of May 19, 2011, it was revealed that the bulk oxygen tank is not inspected annually. According to the bulk oxygen records the last annual inspection was performed on April 2, 2010. Records noted by the Medical Gas vendor stated that the bulk oxygen testing is due to be inspected in March of 2011. When this finding was brought to the attention of the Director of Plant Operations, he notified the Bulk Oxygen vendor who came and inspected the tank on May 24, 2011.

2. While reviewing medical gas testing reports provided from January 13, 2010, September 03, 2010, September 16, 2010, January 13, 2011 and March 10, 2011, it was identified that the Medical Gas system is not properly maintained. The facility has no documentation substantiating that all the issues identified in the January 11, 2010 report have been resolved or that any arrangements have been made to resolve the deficiencies as follows;
- There is no documentation to indicate the replacement of oxygen outlet(s) for the ICU #5 A and the pre-op room #3 that failed during the January 13, 2010 report. There is no record of testing oxygen outlets for rooms #104, the ICU#1 , the x-ray room, cat scan room, Physical Therapy room, #206 A, #206 B and room #223.
-The reports reviewed indicated that 76 vacuum outlets and 52 medical air outlets in resident rooms and resident use rooms have not been tested.
- The lag alarm(s) for the Medical air and vacuum system are not tied to the Master Alarm.
- The dew point/carbon monoxide sensors are not working accurately. The Air Quality monitor should be calibrated monthly and new sensors installed twice a year which is recommended by the Manufacturer.
-The medical air switch and the main line gauge has no gas specific demand check fitting.

3. Based on observation on the morning of May 18, 2011, it was revealed that the medical gas and the vacuum systems were not properly maintained. The facility's two master alarm panels are not supervised in a 24 hour posted location. One of two master alarm panels is located in the business office, the second is located on the closed unit behind the nurses' station on the second floor.

4. Interview with the Director of Plant Operations on the afternoon of May 19, 2011 indicated that one of the three vacuum pumps failed on January 26, 2011. The second of the three vacuum pump failed and was unable to reset on May 06, 2011. The facility repaired and returned the two pumps to service on May 22, 2011.

5. While reviewing policy and procedure records on the morning of May 23, 2011, there are no routine preventative maintenance programs in accordance with the manufacturers' recommendations established for the vacuum piping system and for the secondary equipment attached to the vacuum station inlets to ensure the continued good performance of the entire vacuum system.

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Essential Electrical System" (ESS or EPSS) is maintained, tested, and inspected in accordance with NFPA 99. LSC Section 7.9.3 requires written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction.

NFPA 99,
Section 3.4.4.1.1(b)1 requires generator sets to be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days.
Section 3.4.4.1.3 requires storage batteries used in connection with essential electrical systems to be inspected at intervals of not more than 7 days and to be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Section 3.4.4.2 requires a written record of inspection, performance, exercising period, and repairs to be regularly maintained and available for inspection by the authority having jurisdiction.
NFPA 110
Sections 6.4.1 & 6.4.2 require the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30 minutes.
Section 6.4.5 requires transfer switches to be operated monthly.
Section 6.4.7 requires the routine maintenance and operational testing program to be overseen by a properly instructed individual.
LSC Sections 4.6.12, 7.9.2.3, & 9.1.3

THE FINDINGS INCLUDE:

- Review of the documentation for the maintenance, testing and inspection of the EPSS on the morning of May 20, 2011, revealed that the emergency generator is not tested under load monthly. Interview with the facility's Director of Plant Operations on May 20, 2011 revealed that he did not test the facility's emergency generators under load on a monthly basis during the previous year (2010), nor were weekly inspections conducted on the same emergency generators.
Load testing was not conducted during May 2010, July 2010, or August 2010. Documented load tests conducted on the facility's emergency generators on March 4, 2010, (43 days to) April 16, 2010, (52 days to) June 7, 2010, and (87 days to) September 2, 2010, all exceed the maximum (40 days) allowable test interval between load testing.
In addition,weekly inspections of the emergency generators were not documented.
When prompted for an explanation of the sporadic emergency generator inspection/testing intervals, the facility's Director of Plant Operations indicated that scheduled tests had been scheduled for the "next Friday" did not come about because the "next Friday got pushed ahead."

This was confirmed by the Director of Plant Operations and reviewed with facility representatives during the summary of survey findings.