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Based on observation and interview, the facility failed to ensure that roller latches were not used on corridor doors and failed to maintain their corridor doors for 3 of 11 smoke compartments. This was evidenced by corridors doors with roller latches, corridor doors that were held open in an unauthorized manner and corridor doors that failed to fully close and positive latch. These findings could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

On 1/25/11 to 2/2/11, the corridor doors were observed with the Senior Corporate Director of Plant Operations, the Director of Engineering and the Corporate Consultant and the facility satff were interviewed.

January 25, 2011

1. At 11:10 a.m., in the Nursing Supervisor Office 200, the second door failed to positive latch. The Director of Engineering confirmed that the door failed to latch.

2. At 11:15 a.m., the Clean Utility Room across from Room 212, the corridor door failed to positive latch. The Director of Engineering confirmed that the door failed to latch.

January 26, 2011

3. At 9:45 a.m., the corridor door to OR 1(Operating Room) was equipped with a roller latch.
Staff 1 stated that the roller latches had been there since the hospital opened in 1968.

4. At 9:46 a.m., the corridor door to OR 2 was equipped with a roller latch.

5. At 9:47 a.m., the corridor door to OR 3 was equipped with a roller latch.

6. At 9:48 a.m.,the corridor door to the Auto Clave room was equipped with a roller latch.

7. At 9:50 a.m., the corridor door to OR 4 was equipped with a roller latch.

8. At 10:00 a.m., the corridor door to the Sterilizer Room did not have a latching mechanism.

9. At 10:05 a.m., the corridor door to OR 5 was equipped with a roller latch.

10. At 10:15 a.m., The Senior Corporate Director of Plant Operations, the Director of Engineering and the Corporate Consultant confirmed that there were roller latches in the surgery compartment.

11. At 3:22 p.m., in Patient Room 103, there was tubing taped across the floor to the next room obstructing the corridor door. The Director of Engineering confirmed that the door was blocked from closing.


12. At 3:23 p.m., in Patient Room 104, there was tubing taped across the floor to the next room obstructing the corridor door. The Director of Engineering confirmed that the door was blocked from closing.

Based on observation, the facility failed to maintain the separation wall between the Hospital and the Pediatric Skilled Nursing Facility. This was evidenced by the failure of the double door to positive latch upon closure. This finding could result in the spread of smoke and fire from one area to the adjacent area and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

On January 26, 2011, during fire alarm testing with the Senior Corporate Director of Plant Operations and the Director of Engineering, the separation double door between the Hospital and the Pediatric Skilled Nursing Facility was observed.

At 11:15 a.m., the right leaf of the double door separating the Hospital from the Skilled Nursing Facility failed to fully close and positive latch when released from the door's hold open devices during fire alarm testing. The Director of Engineering confirmed that the separation door failed to latch.

Based on observation, the facility failed to maintain their smoke barrier double doors in 5 of 11 smoke compartments. This was evidenced by smoke barrier doors that failed to fully close and positive latch upon closure. This finding could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During the facility tour and fire alarm testing with the Senior Corporate Director of Plant Operations and the Director of Engineering on January 25, 2011 through February 2, 2011, the smoke barrier doors were observed.

January 25, 2011

1. At 10:25 a.m., the Kitchen Entrance and Exit Corridor Doors located in a fire wall, failed to have latching mechanisms on the doors. The Senior Corporate Director of Plant Operations and the Director of Engineering confirmed that the kitchen entrance and exit doors did not have latching mechanisms.

2. At 10:30 a.m., the smoke barrier double door to Purchasing, the left door leaf failed to positive latch. The Senior Corporate Director of Plant Operations and and the Director of Engineering confirmed that the door to Purchasing failed to latch.

January 26, 2011

3. At 10:30 a.m., the left door leaf of the smoke barrier double door by the Administrative Offices failed to positive latch when released from the magnetic locks during fire alarm testing. The Senior Corporate Director of Plant Operations and and the Director of Engineering confirmed that the left door leaf failed to latch.

4. At 11:10 a.m., the left door leaf of the smoke barrier double door by Room 207 failed to positive latch when released from the magnetic locks during fire alarm testing. The Senior Corporate Director of Plant Operations and and the Director of Engineering confirmed that the left door leaf failed to latch.

Based on observation, the facility failed to protect the corridor from hazardous areas. This was evidenced by a hazardous area door with dismantled self-closing door mechanism and penetrations in the hazardous room wall. These findings could spread smoke and fire from a hazardous area to other areas, in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected 2 of 11 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations and the Director of Engineering on January 27, 2011, the hazardous areas were observed.

1. At 10:40 a.m., in the Environmental Services Supply Room, there was a 4 foot by 6 inch unsealed penetration on the bottom left of the wall by the door. The Director of Engineering confirmed the penetration by the door.

2. At 3:18 p.m., the IT Room formerly Imaging III, the self-closing device to the door was dismantled. The Director of Plant Operations and the Director of Engineering confirmed that the self-closing mechanism to the door was dismantled.

NFPA 72 (1999 Edition) 2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 101 (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by incorrect time registered on the fire alarm panel and obstructed access to manual pull boxes. This affected 4 of 11 smoke compartments. These findings could result in delayed response to fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During the facility tour with the Senior Corporate Director of Plant Operations and the Director of Engineering on January 25, 2011 through February 3, 2011, the fire alarm system was observed and tested.

January 25, 2011

1. At 10:07 a.m., the manual fire alarm pull box in Conference Room A & B was blocked from access by a trash can. The Director of Engineering confirmed that the manual pull box was blocked from access by a trash can.

2. At 2:50 p.m., the manual fire alarm pull box in Rehab Services was blocked from access by a treadmill. The Director of Engineering confirmed that the manual pull box was blocked from access by a treadmill.

3. At 3:30 p.m., the Fire Alarm Control Panel displayed the time as 12:39 p.m. The correct time was 3:30 p.m. The Director of Engineering confirmed the panel read the incorrect time.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained in 5 of 11 smoke compartments. This was evidenced by a missing escutcheon ring, Inspector Test Valves that were blocked from access, sprinkler heads with a build-up of debris and a sprinkler head without an 18 inch clearance. These findings could prevent the sprinkler system from operating as designed and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During a tour of the facility with the Senior Corporate Director of Plant Operations and the Director of Engineering on January 25, 2011 through February 3, 2011, the sprinkler system was observed.

January 25, 2011

1. At 10:22 a.m., in the Kitchen, 1 of 1 sprinklers in the walk-in freezer was blocked by boxes stacked to the ceiling. The Director of Engineering confirmed that the sprinkler head did not have an 18 inch clearance.

2. At 11:20 a.m., in the corridor by the smoke barrier door next to the Administrative Offices, the sprinkler had a build-up of debris. The Director of Engineering confirmed that the sprinkler had a build-up of debris.

3. At 3:10 p.m., in the CT Scan Room, 1 of 3 sprinklers was missing an escutcheon ring. The Director of Engineering confirmed that the sprinkler was missing a sprinkler skirt.

January 26, 2011

4. At 3:35 p.m., in the ICU Break Room, the Inspector Test Valve was blocked from access by a refrigerator. The Director of Engineering confirmed that the ITV was blocked by a refrigerator.

5. At 3:55 p.m., in the Material Management Store Room, the Inspector Test Valve was blocked from access by boxes and supplies. The Director of Engineering confirmed that the ITV was blocked by boxes and supplies.

6. At 4:02 p.m., in the Store Room next to the Material Management Store Room, the Inspector Test Valve was blocked from access by boxes and supplies. The Director of Engineering confirmed that the ITV was blocked by boxes and supplies.

Based on observation and interview, the facility failed to maintain ready access to the portable fire extinguishers and failure to provide a K-Type extinguisher in the Kitchen. These findings could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire. This affected 4 of 11 smoke compartments.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.

Findings:

During a tour of the facility with the Senior Corporate Director of Plant Operations and the Director of Engineering on January 25, 2011 through February 2, 2011, the fire extinguishers were observed.

January 25, 2011

1. At 10:18 a.m., in the Kitchen serving area, the fire extinguisher by the steam table was blocked from acces by a cart. The Director of Engineering confirmed that the fire extinguisher was blocked from access.

2. At 10:20 a.m., in the Kitchen, there was no K type fire extinguisher in the Kitchen. The director of Dietary stated that the Kitchen had a hood suppression system and a ABC fire extinguisher.

3. At 10:27 a.m., in the corridor to the loading dock by the suggestion box, the fire extinguisher was impeded by a table. The Director of Engineering confirmed that the fire extinguisher was blocked from access.

4. At 2:51 a.m., in Rehab Services, the fire extinguisher was impeded by a treadmill. The Director of Engineering confirmed that the fire extinguisher was blocked from access.

Based on observation, the facility failed to provide safety type ashtrays in their designated smoking areas and failed to maintain a safe distance between oxygen storage and designated smoking areas. This was evidenced by the use of open containers for the disposal of cigarette butts and failure to provide a 50 foot distance between oxygen storage and smoking areas. These findings could result in a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with the Director of Engineering on January 25, 2011 through February 2, 2011, the smoking areas were observed.

January 25, 2011

1. At 11:05 a.m., in the Smokers Patio, there was an open container on a patio table with 18 cigarette butts. Director of Engineering confirmed the open container with cigarette butts.

2. At 3:35 p.m., in the designated smoking area located on the backside of the building, there was an open container on the patio table with 36 cigarette butts and a paper carton on top. One of the cigarette butts was still smoldering. The Smoking Area was located around the corner measuring 34 feet from the 1500 liter liquid oxygen tank storage area. The signage on the oxygen storage stated no smoking within 50 feet.

NFPA 70 (1999 Edition), article 110-12(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)


Based on observation, record review and interview, the facility failed to maintain their electrical wiring and equipment. This was evidenced by the failure of an electrical breaker, failure to respond to past electrical problems and failure to plug high wattage appliances directly into electrical receptacles. These findings have the potential for loss of electrical power, electrical shock and fire, causing an increased risk of injury to patients, visitors and staff.

Findings:

During the facility tour, record review and interview with the Director of Plant Operations, the Director of Maintenance and the Corporate Consultant on January 25, 2011 through February 2, 2011 the facility electrical wiring and equipment were observed, maintenance records were reviewed and staff were interviewed.

January 25, 2011

1. At 10:07 a.m., in the Director of Marketing Office, there was a refrigerator plugged into a surge protector instead of directly into an electrical receptacle. The Director of Engineering confirmed the refrigerator was plugged into a surge protector instead of directly into an electrical receptacle.

2. At 3:15 p.m., in the IT room, formerly Imaging III, there was a microwave oven plugged into a surge protector instead of directly into an electrical wall receptacle. Director of Engineering confirmed the microwave oven was plugged into a surge protector instead of directly into an electrical receptacle.

January 26, 2011

3. At 7:50 a.m., there was a disruption of electrical power in the OR I,
(Operating Room) while a procedure/surgery was in progress. Power was reported to be out for 60 seconds by Nurse Surveyor, who was present in OR 1 when the incident happened. At 9:30 a.m., during interview, OR Staff 1 reported the power had gone out 11 times out of 300 surgeries since 2005, 2 times in OR 1. Staff 1 stated that she knew how to bring the power back on by tripping the nearby circuit breaker switch on. Staff 1 stated that the previous Quality Assurance/Infection Control Director was aware of the electrical issues.

4. At 2:15 p.m., the receptacles in the Surgery Department were tested by maintenance staff. The outlet on the right wall in OR 2 located in the 4 outlet receptacle (S27 position 3) failed to work when tested. The Director of Maintenance confirmed that the electrical outlet had failed.

January 27, 2011:

5. At 9:45 a.m., during record review, the vendor report From Therma-Tech stated that the breaker box had tripped and was replaced on March 21, 2008. The Director of Plant Operations and the Director of Maintenance stated that the testings were not done under load in the past. Surveyor asked how long a breaker should last and was told a breaker should last for the life of the building.

6. At 12:12 p.m., during interview, the Bio Engineer stated there had been electrical problems in OR 2 in the past as well.

February 1, 2011:

7. At 10:30 p.m., during record review, the electrical report from a certified electrician on January 28, 2011 stated "the main breaker was tripping off due to age and was found to be weak".

8. At 10:45 p.m., during record review, the infrared report tested under load dated January 27, 2011 showed Breaker 3 faulty connection at "serious incipient" and Breaker 4 faulty connection at "moderate incipient". Repairs were made on same day of the report.