HospitalInspections.org

Based on observation and interview, the facility failed to ensure the rated barriers to its hazardous areas were free of penetrations and the doors with closing and latching hardware closed and latched. This has the potential to affect all patients receiving services at the facility. The facility census was 49 patients.

Findings include:

On 03/20/18 a review of the facility's schematic life safety code drawings was completed. The review revealed the hazardous areas were protected with one hour rated construction.

On 03/20/18 at 1:15 PM a tour was conducted of the first floor was Staff M, Q, R, S and T.

1.On 03/20/18 at 1:34 PM observation above the drop down ceiling of the one hour fire barrier between a storage space and room 117, as seen within the storage space, revealed in the southern wall three conduits with a cumulative annular space.

On 03/20/18 at 1:34 PM in an interview, Staff Q confirmed the finding.

2. On 03/20/18 at 1:45 PM observation above the drop down ceiling of the eastern one hour fire barrier between the storage room (next to room 104) and the corridor, and seen from the corridor, revealed to the right of the door and open junction box with two open conduits: one at the side wall and another at the bottom.

On 03/20//18 at 1:45 PM in an interview, Staff Q confirmed the finding.

3. On 03/20/18 at 1:52 PM observation above the drop down ceiling of the one hour barrier between the conference room and the storage space as seen within the conference room, revealed a 1.5 inch penetration above the television with one black line running to the television.

On 03/20/18 at1:52 PM in an interview, Staff Q confirmed the finding. Staff S said he had had discussion with the cable runners twice.

4. On 03/20/18 at 2:14 PM observation above the drop down ceiling of the northern one hour barrier as seen from within in the wheelchair storage room revealed above heating, ventilation, and cooling ducting a one foot by one foot opening.

On 03/20/18 at 2:14 PM in an interview, Staff Q confirmed the finding.

5. On 03/20/18 at 2:20 PM observation above the drop down ceiling of the southern one hour barrier as seen from within the wheelchair storage room there were three open white tip conduits.

On 03/20/18 at 2:20 PM in an interview, Staff Q confirmed the finding.

6. On 03/20/18 at 2:31 PM observation above the drop down ceiling of the one hour barrier between the therapy lead office and a storage room, as seen from within the office and over the desk, revealed two open one inch open conduits, one with a grey wire traveling out of it and another with blue and yellow lines, one open red conduit with red lines traveling out, and one square penetration with a sprinkler line creating an annular space.

On 03/20/18 at 2:31 PM in an interview, Staff Q confirmed the finding.

7. On 03/20/18 at 2:41 PM observation above the drop down ceiling of the one hour barrier as seen from within the soiled holding room revealed on the walls perpendicular to the plane with the door three open conduits on the one barrier and two open conduits on the opposite.

On 03/20/18 at 2:41 PM in an interview, Staff Q confirmed the finding.

8. On 03/20/18 at 2:45 PM observation of the double doors to the same soiled holding room revealed they did not coordinate to ensure they closed and shut.

On 03/20/18 at 2:45 PM in an interview, Staff Q confirmed the finding.

9. On 03/20/18 at 2:50 PM observation above the drop down ceiling of the one hour barrier between the soiled holding room and treatment room two, as seen from within treatment room two, revealed over the peg board one open conduit with a blue line and one red tip conduit with a red line above the fire strobe.

On 03/20/18 at 03/20/18 in an interview, Staff Q confirmed the finding.

On 03/20/18 at 3:08 PM a tour was conducted of the ground floor with Staff M, Q, R, S and T.

10. On 03/20/18 at 3:33 PM observation of the clean linen door was observed to have closing and latching hardware that did not close and latch when tested.

On 03/20/18 at 3:33 PM in an interview, Staff Q confirmed the finding.

11. On 03/20/18 at 3:48 PM observation above the drop down ceiling of where the corrugated deck meets the one hour barrier that separates the corridor from the maintenance office revealed the corrugated spaces were loosely filled with rock wool.

On 03/20/18 at 3:48 PM in an interview, Staff T confirmed the finding.

12. On 03/20/18 at 3:50 PM observation above the drop down ceiling of the one hour barrier as seen within a storage area diagonal from Stair A, and above a slop sink, a six inch by six inch square was cut into the drywall.

On 03/20/18 at 3:50 PM in an interview, Staff Q confirmed the finding.

13. On 03/20/18 at 4:19 PM observation of the door within in the one hour barrier surrounding the soiled holding room revealed it to have latching hardware that did not latch when tested.

On 03/20/18 at 4:19 PM in an interview, Staff Q confirmed the finding.

14. On 03/20/18 at 4:21 PM observation above the drop down ceiling of the one hour barrier separating the corridor from a central storage area as seen from within the corridor and to the right of a poster and fire extinguisher revealed a sewer pipe by heating, ventilation, and cooling ducting with a partial annular space.

On 03/20/18 at 4:21 PM in an interview, Staff Q confirmed the finding.

On 03/21/18 at 9:05 AM the tour of the ground floor resumed with Staff M, Q, R and S.

15. On 03/21/18 at 9:05 AM observation above the drop down ceiling of the one hour barrier as seen within central storage and near the doors revealed an open half inch white tipped conduit.

On 03/21/18 at 9:05 AM in an interview, Staff Q confirmed the finding.

16. On 03/21/18 at 9:14 AM observation above the drop down ceiling of the one hour barrier as seen within central storage in the northeast corner revealed an open conduit with a red wire running out of it.

On 03/21/18 at 9:14 AM in an interview, Staff Q confirmed the finding.

17. On 03/21/18 at 9:43 AM observation above the drop down ceiling of the one hour barrier between the kitchen office and the freezer, as seen from within the office, revealed a two foot long by one foot wide polygon with a pipe running through it.

On 03/21/18 at 9:43 AM in an interview, Staff T confirmed the observation.

18. On 03/21/18 at 10:06 AM observation above the drop down ceiling of the one hour barrier between the pharmacy and the elevator room revealed in the area above the white board revealed a one inch open conduit with a yellow wire running out of it and to the right of that a diamond shaped polygon penetration.

On 03/21/18 at 10:06 AM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to ensure its fire alarm system was tested and inspected in accordance with NFPA 72, 14.6.2.4, 2010 edition. This has the potential to affect all patients receiving services at the facility. The facility census was 49 patients.

Findings include:

A review of the facility's life safety code documentation was completed on 03/22/18. The review revealed from year to year a varying number of devices and therefore unable to determine if each device had been tested yearly.

The 10/06/15 inspection report listed 29 horn/strobes. The 10/28/16 to 11/18/16 inspection report listed 66 horn/strobes. The 11/07/17 to 11/13/17 inspection report listed 60 horn/strobes.

On 03/22/18 at 3:00 PM in an interview, Staff R and S confirmed the finding.

In addition, the review of the alarm inspection report of 11/07/17 revealed device 21:av-113 was recorded as a horn/strobe and assessed as passed inspection.

On 03/21/18 at 4:55 PM device 21:av-113 was observed to be a strobe only.

On 03/21/18 at 4:55 PM in an interview, Staff S confirmed the finding.

The review of alarm inspection report of 11/07/17 revealed device 21:av-120 was noted as a strobe only and assessed passed inspection.

On 03/21/18 at 4:55 PM device 21:av-120 was observed to be both a horn and strobe.

On 03/21/18 at 4:55 PM in an interview, Staff S confirmed the finding.

Based on document review and interview, the facility failed to inspect its sprinkler tamper devices in accordance with 9.7.5 of NFPA 101, 2012 edition, and therefore 5.1.1.2 of NFPA 25, 2011 edition, to perform an internal pipe inspection in accordance with 14.2.1 of NFPA 25, and to change gauges in accordance with 13.2.7 of NFPA 25. This has the potential to affect all patients receiving services at the facility. The facility census was 49 patients.

Findings include:

A review of the facility's life safety code documentation was completed on 03/22/18. The review revealed the sprinklers' tamper switches were inspected on 01/26/17, 07/06/17, 09/25/17 but not on 12/29/17.

On 03/22/18 at 3:00 PM in an interview, Staff R confirmed the finding explaining he thought it was done semiannually.

A review of the inspection and testing form dated 07/06/17 revealed 11 gauges need replaced and a five year internal inspection of the sprinkler system was due.

On 03/22/18 at 8:45 AM in an interview, Staff S could not say whether the internal inspection was done or the gauges had been replaced.

Based on observation and interview, the facility failed to ensure its smoke barrier was free of penetrations. This has the potential to affect all patients receiving services at the facility. The facility census was 49 patients.

Findings include:

On 03/21/18 at 9:05 AM the tour of the ground floor resumed with Staff M, Q, R and S.

1.On 03/21/18 at 10:33 AM observation above the drop down ceiling of the barrier between the bathroom in the physician's lounge and the classroom revealed a two inch by two inch square cut into one layer of drywall to allow for a one inch corrugated conduit, and also a half inch open conduit with a blue line running out of it was observed.

On 03/21/18 at 10:33 AM in an interview, Staff Q confirmed the finding.

2. On 03/21/18 at 10:38 AM observation above the drop down ceiling of the barrier between the hallway and the classroom, as seen from the hallway, revealed just to the left of the monitor, a one inch open conduit with white, purple, and red wiring running out of it.

On 03/21/18 at 10:38 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its fire drills included the transmission of a fire alarm signal and were held at unexpected times in accordance with NFPA 101, 2012 edition, 19.7.1.4 and 19.7.1.6. This has the potential to affect all patients receiving services at the facility. The facility census was 49 patients.

Findings include:

On 03/22/18 a review of the facility's life safety code documentation was completed on 03/22/18.

A review of the facility's fire drills revealed for 2017 fire drills were conducted on 03/22/17 at 3:30 PM, on 06/28/17 at 3:45 PM, on 09/27/17 at 3:30 PM, and again on 12/20/17 at 3:45 PM.

On 03/21/17 at 2:25 PM in an interview, Staff M confirmed the times of when the drills for the second shift were conducted.

The review revealed when the drills were conducted on the night shift on 02/02/17 at 1:45 AM, on 06/13/17 at 1:00 AM, on 09/19/17 at 11:00 PM, and on 10/19/17 at 2:00 AM, a signal had not been sent to the monitoring station.

On 03/21/17 at 2:25 PM in an interview, Staff M confirmed the signal had not been sent.

Based on interview, policy review, and document review, the facility failed to inspect its medical gas system in accordance with NFPA 99, 2012 edition, 5.1.14.2.3. This has the potential to affect all patients receiving services at the facility. The facility census was 49 patients.

Findings include:

A review of the facility's medical gas maintenance policy revealed zone valves and gas outlets are all to be inspected annually.

A review of the facility's life safety code documentation was completed on 03/22/18. The review revealed the medication gas system was inspected on 09/22/16. A review of that inspection report revealed 46 outlets were tested.

The review revealed the medication gas system was inspected on 09/27/17. A review of that inspection report revealed 61 outlets were tested, including those in rooms 211, 210, 204, and 221-which did not appear on the 2016 report.

On 03/22/18 at 8:45 AM in an interview, Staff S confirmed the finding, explaining only a sample of outlets were inspected each year.

Based on interview and observation, the facility failed to ensure it had an annunciator hard wired and in a location in constant observance by personnel in accordance with 6.4.1.1.17 and 6.4.1.1.17.5 of NFPA 99, 2012 edition. This has the potential to affect all patients receiving services at the facility. The facility census was 49 patients.

Findings include:

On 03/20/18 at 3:48 PM the door to the maintenance office was observed to be locked. After entrance was gained, no personnel were present in the room. An annunciator panel for the generator was observed in the corner by the desk.

On 03/22/18 at 3:56 PM in an interview, Staff Q, R, S and T explained they use an automation system to notify their mobile devices in lieu of the annunciator panel being unobserved.