HospitalInspections.org

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital and the clinic. Findings include:

1. Observation at 9:45 a.m. on 8/06/13 revealed three doors located in the two hour wall between the clinic (building 05) and the hospital (building 03).

Doors in two hour fire-rated separation walls are only permitted in corridors (the clinic is not sprinklered). The clinic x-ray rooms and the CT room and the hospital corridor must be provided with smoke detectors interconnected to the fire alarm system. Each of the smoke detectors must be situated within five feet of the door in the two hour wall for this unique application.

Interview with the director of plant operations at 4:00 p.m. on 8/06/13 revealed he was unaware the three doors into the clinic through the two hour rated wall did not meet the standard.

Based on observation and interview, the provider failed to maintain hazardous room doors in operating condition. One randomly observed 60 minute fire-rated corridor door (Central Supply) was held in the open position by an unapproved device. Findings include:

1. Observation at 9:30 a.m. on 8/06/13 revealed the 60 minute fire-rated corridor door for the Central Supply room was held in the open position with a rubber floor wedge. That device was an impediment to closing the door in an emergency and reduced the fire resistiveness of the one-hour fire barrier. Interview with the director of environmental services at the time of the observation revealed a magnetic hold open tied into the fire alarm system could be installed on the door.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The storage room adjacent to the ambulance garage was not equipped with a closer. Findings include:

1. Observation at 1:45 p.m. on 8/06/13 revealed the storage room adjacent to the ambulance garage was 11 feet by 16 feet and the corridor door was not equipped with a closer. Interview with the director of environmental services at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to separate the furnace room from the sleep study area on the main floor (building 06). Findings include:

1. Observation at 8:45 a.m. on 8/06/13 revealed the furnace room was not separated with one-hour fire-rated construction from the sleep study area on the main floor (building 06) at 311 W. 4th Street. Interview with the respiratory therapist at the time of the observation confirmed that finding.

Based on record review and interview, the provider failed to ensure monthly fire drills were performed during the previous twelve months. Record review of the previous fourteen months (July 2012 through August 2013) fire drill reports revealed drills were not performed July through November 2012 or January through April 2013. Findings include:

1. Review of the provider's fire drill reports for the previous fourteen months (July 2012 through August 2013) revealed drills were not performed July through November 2012 or January through April 2013.

Interview with the director of environment services at 4:00 p.m. on 8/06/13 revealed quarterly fire sprinkler tests had not been performed during those time periods during building construction and remodeling.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had the required quarterly flow testing performed during the previous twelve months. Record review of the previous fourteen months (July 2012 through August 2013) fire sprinkler system inspections revealed quarterly flow testing documentation was not available. Findings include:

1. Review of the provider's fire sprinkler reports revealed the only sprinkler system documentation available between July 2012 and August 2013 was 6/11/13. Interview with the director of environment services at 4:00 p.m. on 8/06/13 revealed quarterly fire sprinkler tests had not been performed during those time periods during building construction and remodeling.

Based on observation and interview, the provider failed to supply a fire extinguisher in the sleep study area (building 06). Findings include:

1. Observation at 8:45 a.m. on 8/06/13 revealed a fire extinguisher was not supplied for the sleep study (building 06) at 311 W. 4th Street. Interview with the respiratory therapist at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to restrain randomly observed oxygen cylinders in the storage room adjacent to the ambulance garage and at the fire sprinkler riser. The provider also failed to restrain two of two large (size L) portable oxygen cylinders in a secured position. Oxygen cylinders were not secured in the upright position in the liquid oxygen storage/manifold room. (See attached NFPA 99, Standard for Health Care Facilities, section 8-3.1.11.2(h) Storage Requirements.) Randomly observed oxygen cylinders were not secured at the fire sprinkler riser and in the storage room adjacent the ambulance garage. Findings include:

1. Observation beginning at 10:15 a.m. on 8/06/13 revealed two randomly observed size C oxygen cylinders in the storage room adjacent to the ambulance garage in an upright, unsecured position. There were four randomly observed size C oxygen cylinders adjacent to the fire sprinkler riser in an upright position that were not secured.

2. Observation at 2:00 p.m. on 8/06/13 revealed two size L liquid oxygen cylinders unrestrained in the oxygen manifold room (adjacent to the boiler room).

Interview with the director of environmental services at 4:00 p.m. on 8/06/13 acknowledged those findings. He further revealed maintenance was unaware there were cylinders that were unrestrained.

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital (building 03) and adjacent buildings (clinic-building 05 and the assisted living center). Findings include:

1. Observation at 8:45 a.m. on 8/06/13 revealed an unsealed three inch diameter electrical conduit with control wiring above the lay-in ceiling through the two hour wall in the corridor to the main entrance between the clinic and the hospital. Further observation revealed the special fire seal pillows were not in the conduit but were on top of the lay-in ceiling in the area.

2. Observation at 9:00 a.m. on 8/06/13 revealed an unsealed opening at a control wire penetration of the two hour wall between the hospital (building 03) and the clinic (building 05) above the lay-in ceiling at the radiology office.

3. Observation at 9:15 a.m. on 8/06/13 revealed an unsealed 1-1/2 inch conduit with control wiring above the lay-in ceiling through the two hour wall in the corridor to the assisted living center. There were also unsealed conduits in the two hour wall between the exit corridor (adjacent patient room 6) and the assisted living kitchen above the lay-in ceiling.

Interview with the director of environmental services at 4:00 p.m. on 8/06/13 confirmed those findings.

Based on testing, observation, and interview, the provider failed to maintain an alternate source of power. The generator did not start when tested. Findings include:

1. Testing and observation at 12:30 p.m. on 8/06/13 revealed the 200 kva Generac diesel generator timed out after about 13 seconds and did not start. A second test attempt at the generator resulted in the generator starting 7 seconds after initiating the start sequence. Interview with the director of environmental services at the time of the testing and observation revealed the generator had been serviced less than a month prior to the survey and had functioned normally at that time. He further indicated he would be in contact with the service company as soon as possible and have the problems with the generator corrected immediately.

Based on observation and interview, the provider failed to provide ground-fault circuit-interrupter (GFCI) protection for personnel in one randomly observed room (emergency intensive care unit room). Findings include:

1. Observation and testing at 10:00 a.m. on 8/06/13 revealed two wall outlets within six feet of a sink in the emergency intensive care unit (EICU) room. Testing revealed those outlets were not GFCI protected. Interview with the director of environmental services at the time of the observation confirmed those conditions. He stated GFCI receptacles would be installed in those locations as soon as possible.

Based on observation and interview, the provider failed to provide permanent wiring. An extension cord was being used in the northeast patient sleeping room for the TV. Findings include:

1. Observation at 8:45 a.m. revealed an extension cord in use in place of permanent wiring in the northeast patient sleeping room for the TV. Interview with the respiratory therapist at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital and the clinic. Findings include:

1. Observation at 9:45 a.m. on 8/06/13 revealed three doors located in the two hour wall between the clinic (building 05) and the hospital (building 03).

Doors in two hour fire-rated separation walls are only permitted in corridors (the clinic is not sprinklered). The clinic x-ray rooms and the CT room and the hospital corridor must be provided with smoke detectors interconnected to the fire alarm system. Each of the smoke detectors must be situated within five feet of the door in the two hour wall for this unique application.

Interview with the director of plant operations at 4:00 p.m. on 8/06/13 revealed he was unaware the three doors into the clinic through the two hour rated wall did not meet the standard.

Based on observation and interview, the provider failed to maintain hazardous room doors in operating condition. One randomly observed 60 minute fire-rated corridor door (Central Supply) was held in the open position by an unapproved device. Findings include:

1. Observation at 9:30 a.m. on 8/06/13 revealed the 60 minute fire-rated corridor door for the Central Supply room was held in the open position with a rubber floor wedge. That device was an impediment to closing the door in an emergency and reduced the fire resistiveness of the one-hour fire barrier. Interview with the director of environmental services at the time of the observation revealed a magnetic hold open tied into the fire alarm system could be installed on the door.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The storage room adjacent to the ambulance garage was not equipped with a closer. Findings include:

1. Observation at 1:45 p.m. on 8/06/13 revealed the storage room adjacent to the ambulance garage was 11 feet by 16 feet and the corridor door was not equipped with a closer. Interview with the director of environmental services at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to separate the furnace room from the sleep study area on the main floor (building 06). Findings include:

1. Observation at 8:45 a.m. on 8/06/13 revealed the furnace room was not separated with one-hour fire-rated construction from the sleep study area on the main floor (building 06) at 311 W. 4th Street. Interview with the respiratory therapist at the time of the observation confirmed that finding.

Based on record review and interview, the provider failed to ensure monthly fire drills were performed during the previous twelve months. Record review of the previous fourteen months (July 2012 through August 2013) fire drill reports revealed drills were not performed July through November 2012 or January through April 2013. Findings include:

1. Review of the provider's fire drill reports for the previous fourteen months (July 2012 through August 2013) revealed drills were not performed July through November 2012 or January through April 2013.

Interview with the director of environment services at 4:00 p.m. on 8/06/13 revealed quarterly fire sprinkler tests had not been performed during those time periods during building construction and remodeling.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had the required quarterly flow testing performed during the previous twelve months. Record review of the previous fourteen months (July 2012 through August 2013) fire sprinkler system inspections revealed quarterly flow testing documentation was not available. Findings include:

1. Review of the provider's fire sprinkler reports revealed the only sprinkler system documentation available between July 2012 and August 2013 was 6/11/13. Interview with the director of environment services at 4:00 p.m. on 8/06/13 revealed quarterly fire sprinkler tests had not been performed during those time periods during building construction and remodeling.

Based on observation and interview, the provider failed to supply a fire extinguisher in the sleep study area (building 06). Findings include:

1. Observation at 8:45 a.m. on 8/06/13 revealed a fire extinguisher was not supplied for the sleep study (building 06) at 311 W. 4th Street. Interview with the respiratory therapist at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to restrain randomly observed oxygen cylinders in the storage room adjacent to the ambulance garage and at the fire sprinkler riser. The provider also failed to restrain two of two large (size L) portable oxygen cylinders in a secured position. Oxygen cylinders were not secured in the upright position in the liquid oxygen storage/manifold room. (See attached NFPA 99, Standard for Health Care Facilities, section 8-3.1.11.2(h) Storage Requirements.) Randomly observed oxygen cylinders were not secured at the fire sprinkler riser and in the storage room adjacent the ambulance garage. Findings include:

1. Observation beginning at 10:15 a.m. on 8/06/13 revealed two randomly observed size C oxygen cylinders in the storage room adjacent to the ambulance garage in an upright, unsecured position. There were four randomly observed size C oxygen cylinders adjacent to the fire sprinkler riser in an upright position that were not secured.

2. Observation at 2:00 p.m. on 8/06/13 revealed two size L liquid oxygen cylinders unrestrained in the oxygen manifold room (adjacent to the boiler room).

Interview with the director of environmental services at 4:00 p.m. on 8/06/13 acknowledged those findings. He further revealed maintenance was unaware there were cylinders that were unrestrained.

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital (building 03) and adjacent buildings (clinic-building 05 and the assisted living center). Findings include:

1. Observation at 8:45 a.m. on 8/06/13 revealed an unsealed three inch diameter electrical conduit with control wiring above the lay-in ceiling through the two hour wall in the corridor to the main entrance between the clinic and the hospital. Further observation revealed the special fire seal pillows were not in the conduit but were on top of the lay-in ceiling in the area.

2. Observation at 9:00 a.m. on 8/06/13 revealed an unsealed opening at a control wire penetration of the two hour wall between the hospital (building 03) and the clinic (building 05) above the lay-in ceiling at the radiology office.

3. Observation at 9:15 a.m. on 8/06/13 revealed an unsealed 1-1/2 inch conduit with control wiring above the lay-in ceiling through the two hour wall in the corridor to the assisted living center. There were also unsealed conduits in the two hour wall between the exit corridor (adjacent patient room 6) and the assisted living kitchen above the lay-in ceiling.

Interview with the director of environmental services at 4:00 p.m. on 8/06/13 confirmed those findings.

Based on testing, observation, and interview, the provider failed to maintain an alternate source of power. The generator did not start when tested. Findings include:

1. Testing and observation at 12:30 p.m. on 8/06/13 revealed the 200 kva Generac diesel generator timed out after about 13 seconds and did not start. A second test attempt at the generator resulted in the generator starting 7 seconds after initiating the start sequence. Interview with the director of environmental services at the time of the testing and observation revealed the generator had been serviced less than a month prior to the survey and had functioned normally at that time. He further indicated he would be in contact with the service company as soon as possible and have the problems with the generator corrected immediately.

Based on observation and interview, the provider failed to provide ground-fault circuit-interrupter (GFCI) protection for personnel in one randomly observed room (emergency intensive care unit room). Findings include:

1. Observation and testing at 10:00 a.m. on 8/06/13 revealed two wall outlets within six feet of a sink in the emergency intensive care unit (EICU) room. Testing revealed those outlets were not GFCI protected. Interview with the director of environmental services at the time of the observation confirmed those conditions. He stated GFCI receptacles would be installed in those locations as soon as possible.

Based on observation and interview, the provider failed to provide permanent wiring. An extension cord was being used in the northeast patient sleeping room for the TV. Findings include:

1. Observation at 8:45 a.m. revealed an extension cord in use in place of permanent wiring in the northeast patient sleeping room for the TV. Interview with the respiratory therapist at the time of the observation confirmed that finding.