HospitalInspections.org

Based on observation the facility failed to maintain the fire alarm system operation at the Nix Medical Center.

The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues:

A.) An audible and visible fire alarm notification device need to be installed inside the OR Locker rooms.

"Audible and visible fire alarm notification appliances shall be used only for fire alarm system or other emergency purposes..." - NFPA 101, 2000, 9.6.3.11

The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues at the Nix Medical Center:

A) There were missing sprinkler escutcheon plates at the following area: 6th floor IT room, 20th floor patient room, 23rd floor scope work room, and the kitchen storage room.
B) There was a missing sprinkler head at the break room 707.
C) There was storage of items above an 18 inch plane below the sprinkler head shields in the following spaces: IT Room 602.


"Any fire protection system, building service equipment, feature of protection, or safe guard provided for life safety shall be designed, installed, and approved in accordance with applicable NFPA standards. - NFPA 101, 2000: 4.5.6.

Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.

A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

Based on observation the facility failed to provide adequate medical gas system storage requirement at the Nix Medical Center.

The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues:

A.) There was no signage or incorrect provided at the Medical Gas Storage Room exterior and interior door. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

Where nitrous oxide is used, the medical gas closet shall have a door labeled:

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues at the Nix Medical Center:

A.) There were contact between copper medical gas piping and electrical conduit in the ceiling of the smoke compartment where the cross corridor doors are located on the 18th floor.

" Copper medical gas piping shall be separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action. " - NFPA 99, 2002: 5.1.10.6.4

The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues at the Nix Medical Center:

1) Scab-on patches were observed at smoke compartment walls above cross corridor doors on floors 18th, 19th, and 20th. Going forward for new construction or renovation projects, holes are to be patched with taped and floated rated gypsum board screwed to studs flush with existing.

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers and smoke barriers shall be sealed to prevent the passage of smoke and the products of combustion, with a material capable of maintaining the fire resistance of the fire barrier. " - NFPA 101, 2003: 8.3.5 and 8.5.5.

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The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues at the Nix Medical Center:

1) Line isolation monitor - Grounding system testing logs provided did not have adequate history.
2) The biomedical electrical semi-annual and annual inspection and testing logs provided did not have adequate history.
3) The biomedical electrical semi-annual testing was overdue for one defibrillator on the 18th floor.

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The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues at the Nix Medical Center:

1) There were junction boxes without covers in the Mechanical Room of 2nd floor.

All junction boxes of any nature are required to have properly secured cover plates with all wiring secured inside. - NFPA 70, National Electrical Code. U.S.A.: NFPA; 2002:314-28(C) and 314-24.

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The inspector observed, while accompanied by The Director of Performance Improvement and Education Patient Safety Office, Facility Operations Manager, and Maintenance Technician during the hours of the inspection from 9 AM to 2 PM on 10/21/2015, that there was the following issues at Nix Behavioral Health Center:

1) There was a junction box without cover in the ceiling space above the smoke compartment wall at the cross corridor doors in the Adult Unit 2nd floor (northwest).

All junction boxes of any nature are required to have properly secured cover plates with all wiring secured inside. - NFPA 70, National Electrical Code. U.S.A.: NFPA; 2002:314-28(C) and 314-24.

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The inspector observed, while accompanied by The Vice President of Facility Operations, and The Facility Mechanic during the hours of the inspection from 9 AM to 2 PM on 10/21/2015, that there was the following issues at Nix Special Helath Center:

1) The biomedical electrical semi-annual and annual inspection and testing logs provided did not have adequate history.

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The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues at the Nix Medical Center:

A.) There were two missing door closer at the following hazardous areas: Dry Storage Room in Dietary suite.
B.) The Mechanical Room inside the 17th floor Laboratory is missing a door closer.
C.) There was missing fire rated door or door frame rating at the following hazardous areas: Soiled Work Rooms and the stairwell door frame.
D.) The door to Mechanical Room on the 24th floor does not latch.
E.) The door to Mechanical Room on the 20th floor (south) does not latch.
F.) There was a large opening in the wall of the Mechanical Room in the 2nd floor.


Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 10.2.2.3. NFPA 101, 2003, 20.3.2.1.

Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. " - NFPA 101, 2003, 8.3.4.1

Smoke barriers required shall be continuous from an outside wall to outside wall, from a floor to a floor or from smoke barrier to a smoke barrier, or a combination thereof - NFPA 101, 2003: 8.5.2.1.

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The inspector observed, while accompanied by The Vice President of Facility Operations, and The Facility Mechanic during the hours of the inspection from 9 AM to 2 PM on 10/21/2015, that there was the following issues at Nix Specialty Health Center:

A.) There were door stop wedge located at the dry storage room at the dietary suite. Please remove the door stop wedge.
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The inspector observed, while accompanied by The Chief Nursing Officer, The Vice President of Facility Operations, The Director of Performance Improvement and Education Patient Safety Office, The Facility Operations Manager during the hours of the inspection from 9 AM to 5 PM on 10/20/2015, that there was the following issues at the Nix Medical Center:

A.) The electrical connection between the panel/breaker and the FACP was not cross referenced correctly. Please provide label on the outside of the FACP panel as required.

The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3.