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Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls with at least one-half hour fire resistance rating. Findings:

1) The Draw Station Alcove, located at the entrance to the Lab, is open to the corridor. There is not a one-half hour fire resistance rating separating this use area from the corridor. Refer to 19.3.6.1.

2) Section 19.3.6.2.1, Exception No. 1 reads "in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke". The suspended acoustical ceiling was found to have damaged tiles at various locations in the facility, thus rendering it unable to limit the transfer of smoke at those locations.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the doors closed. Findings:

1) There is no latching hardware on two doors opening from the corridor in the Birthing Center. The doors into the Soiled Room and one of the former Dressing Rooms do not have latching hardware. Refer to 19.3.6.3.2.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are at least one-half hour fire resistance rating. Findings:

1) Open penetrations were found in the smoke compartment wall (smoke barrier); including, around wiring, conduit and ductwork passing through the wall.

Based on observation, review of Fire Alarm Annual Reports, and interview with staff, the facility failed to provide a fire alarm system that is installed with components, devices and equipment that is maintained and tested for compliance with NFPA 70, and NFPA 72. 9.6.1.4 Findings include:

1. On January 4, 2013, the facility had a fire alarm and suppression system inspection by the
Simplex Grinnell Company; findings revealed,
a) The magnetic locks for the Mental Health exit doors did not release upon fire alarm
activation. The same condition had been noted on the June 27, 2012 fire alarm inspection
report.
b) The magnetic locks to the Birthing Area did not release upon fire alarm activation.
c) The 12 V, 18 Ah batteries in the fire alarm control panel failed.
d) On both reports, the facility failed to provide documentation that staff had read and signed
the reports, there were no signatures on the inspection reports
2. Based on interview with staff member CC, the Smoke Evacuation system for the Operating Room was tied in (date not known) using temporary power (yellow extension cord) to tie in dampers. The cords were plugged into a Blue Control Panel located in the Mechanical Closet supplying Operating Room 1. There is no supporting documentation that the smoke evacuation equipment worked and the facility failed to document by the required reacceptance test in accordance with NFPA 72, 1999 edition, chapter 7-1.6.2.2.

3. The information noted above for the Magnetic Locks indicates the facility does not have an inspection, testing, and maintenance program that assures staff are summoned and that equipment is installed properly and that control functions work to manufacturer's specification in accordance with the provisions of NFPA 72, 1999 edition.

Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90 A, 19.5.2.2 Findings include:

The HVAC Systems serving the Operating Rooms 1 and 2, located between the emergency generator and rear entrance, was in the process of being renovated; however, at the time of the survey, no work or servicing of equipment was being conducted. Water was leaking profusely from the bottom of the left unit, the newly installed control panels were open with an extension cord plugged into the control panel. During the tour of the facility, conducted on 9/17/013 at 2;30 PM, the surveyor asked staff member CC the purpose of extension cord. The maintenance person CC explained that it connected the newly installed smoke control dampers. The Surveyor also noted the New filter banks were installed about 5 feet above finished floor, filter bank included a HEPA and a Pre-Filter. Duct Humidifiers could not be located, Humidifiers shall be located at least fifteen (15) feet in front of the final filters or be fitted with water removal devices that do not allow any water droplets to reach the filter. Humidifiers shall be connected to airflow proving switches that prevent humidification unless the required volume of airflow is present or high limit humidity are provided. All duct take offs should be sufficiently downstream of the humidifier to ensure complete moisture dissemination". The facility failed to install the required Manometer to depict pressure loss across filter bank. On 9/17/2013 the surveyor reviewed Humidity Logs, surveyor noted multiple entries that depicted Chronic high levels of Humidity, surveyor requested humidity logs for January of 2012 through present day; however, logs were unavailable prior to May of this year. Surveyor requested a Certified Test and Balance Report for the Operating Room Suite, none was available .

Repairing/ Modernizing the HVAC System for the Operating Room Suite will require the equipment to be replaced. LSC/CMS Letter dated December 11, 2003; Subject, Definitions and Terms used in the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), provides direction for dealing with this citation. Renovation of an existing system requires the facility to submit for review in accordance with Hospital Standards Chapter 667-47, and provide a narrative with scope of work and stamped set of plans and specifications.

The exhausts fans for the soiled utility areas and sterilizer room were not running on September 17, or on September 18, the maintenance and supervisory staff were ask for an update on exhaust fans; the maintenance person indicated that both motors on the fans were burnt out.

Surveyor noted that the Soiled work room in the Operating Room Suite was not provided with a dedicated Exhaust.

Documentation for positive air movement and air exchanges in accordance with Hospital Standards Chapter 667 Appendix A "Clean Sterile Processing Room", was not provided.

Surveyor noted the endo-scope cleaning room was not documented as negative; there was no clean side to the scope processing area; there was no flow to the room or rooms that provided a dirty to clean, to final storage.

Further investigation determined that of the approximately 20-25 exhaust fans that were on the roof, half were burnt up and not working, as indicated by maintenance staff CC. While on the roof, this surveyor was almost stung by Wasp from a large nest. Staff CC indicated that the facility did not have a comprehensive Preventive Maintenance Program.

Surveyor noted there are fresh air intakes that were less than 3 feet above roof line; also, the water is not draining off the roof and is pooled under fresh air intakes.

Based on observation and interview with staff, the facility failed to provide means of egress continuously maintained free of all obstructions or impediments to full instant use in case of emergency. Refer to 7.1.10.1. Findings:

1) Equipment and wheel chairs were found stored in the corridor across from the Nurse Station in the Emergency Department.

2) Storage shelving and equipment was found in the Restricted Corridor in the Surgery Suite.

Based on observation and interview with staff, on September 17, 2013 at 2:30 PM, the facility failed to provide a Piped in Medical Gas Systems that is in compliance with NFPA 99 1999 edition, chapter 4. Findings include:

Surveyor reviewed a 2-page Medical Gas Certification prepared by Air Safe, dated September 19, 2013, submitted by the facility on September 20, 2013, the report submitted failed to mention the Liquid Reserve Tank. A report e-mailed on September 23, 2013 by Air Safe, also dated September 19, 2013, depicted Liquid Reserve; however, there is a deficiency on page 2 (opening may not be within 10 feet of the bulk site, the facility failed to separate the Bulk Site from the opening to the Purchasing Building). The Bulk Site addition requires the facility to meet new construction requirements. NFPA 55 2005 edition chapter 9.3.2.1 (3) (SEE MEDICAL GAS CERTIFICATION REPORT, Dated SEPTEMBER 19, 2013 BULK OXYGEN STATION) . LSC/CMS Letter dated December 11, 2003; Subject; Definitions and Terms used in the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) provides direction for dealing with this citation. Renovation of an existing system requires the facility to submit for review in accordance with Hospital Standards Chapter 667-47, and provide a narrative with scope of work and stamped set of plans and specifications.

Staff member CC indicated that the Vacuum Supply to the Operating Room had to be turned off when not being used, due to the line leaking and making the Vacuum pumps run.

The facility failed to provide an Emergency Fill Station (see NFPA 99, 1999 edition chapter 4-3.1.1.8 (h)).

Based on observation and interview with staff, the facility failed to provide a Type 1 Essential Electrical system in accordance with NFPA 99. Findings:

1) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating area in a location readily observed by operating personnel at a regular work station.. The facility does not have a remote annunciator in a readily observed area. Refer to 3-4.1.1.15.

2) Battery powered emergency lighting shall be provided at the transfer switch. The facility does not have battery powered emergency lighting at the transfer switch. Refer to NFPA 110, Section 5-3.1.

3) Battery powered emergency lighting shall be provided at each Operating Room and operate immediately upon loss of power. The facility does not have battery powered emergency lighting in each Operating Room. Refer to NFPA 110, Section 517.63.

Based on observation and interview with staff, the facility failed to provide a maintenance program including whenever or whatever device, equipment, system, condition, arrangement, level of protection, or any other feature that is required for compliance with the provisions of this Code. Such devices, equipment, system condition, arrangement, level of protection, or other features shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction in accordance with NFPA 101, 2000 Edition, Chapter 4.6.12.1. Findings include:

When staff member CC and the surveyor returned from the roof, staff member U was asked for a written preventive maintenance program. Staff member U stated that the facility did not have one, however, it would be on the to-do list.

Example: 20 to 25 powered exhaust fans had never been on a preventive maintenance program. Wasps were in the fans, preventing blades from turning and half of the fans did not work.

The HVAC unit serving the OR was leaking condensate water, the insulation was removed allowing the pipes to drip condensate water.
Based on observation, review of annual inspection reports, and interview with staff, the facility failed to provide an automatic sprinkler system that it shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. Findings include:

1. Several 155 degree quick response pendant sprinklers are installed within one foot of air vents. Sprinklers need to be relocated and, or, sprinklers changed to a higher temperature in order to prevent premature discharge of sprinklers.
2. No sprinkler protection in closet in hall by room 104.
3. No sprinkler protection in two closets in hallway by Drug Room.
4. Server room has no sprinkler protection in it.
5. No annual tests and inspections on back flow preventer.
6. No 5-year internal inspection documentation of all system piping in last five years. Documentation was not available.
7. Two pendant sprinklers have paint over-spray on them, one located in the bathroom of room 108, and one in the bathroom of room 110.
8. Missing one chrome semi-recessed escutcheon in men's bathroom by boiler room.

West System-Green Tagged.
1. Several 155 degree quick response pendant sprinklers are installed within one foot of air vents. Sprinklers shall be relocated and, or, sprinklers changed to a higher temperature in order to prevent premature discharge of sprinklers.
2. A 5-year internal inspection of all system piping shall be done if not done in the last five years.
3. Annual tests and an inspection on the back blow preventer shall be done.
4. One inch globe valve on ITV is bad and needs to be replaced before the next inspection. A survey will need to be done to determine the exact count of sprinklers within one foot of air vents as indicated by Simplex/Grinnel inspection dated January 4, 2013. There is no sprinkler coverage over the receiving area across from the dining room. There is no sprinkler coverage to the covered area, Storage Area for Red Plastic Bio Waste Containers near the emergency generator.

Reports could not be documented as being reviewed by the owner or even read; reports were not signed.

Based on observation and interview with staff, the facility failed to provide a fire sprinkler system in accordance with 19.3.5. Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width. Refer to NFPA 13, Section 5-13.8.1. Findings:

1) There is no fire sprinkler coverage for the area under exterior roof at the exit southwest of the Boiler Room.

2) There is no fire sprinkler coverage for the area under the exterior roof at the northwest exit leading from the Administration area.

Based on observation and interview with staff, the facility failed to provide a Type 1 Essential Electrical system in accordance with NFPA 99 - 1999 Edition. Findings:

1) The facility failed to provide a Type 1 EES comprised of two separate systems; the Emergency System and the Equipment System. The Emergency System shall be divided into the Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3.4.2.2.2 (b) and (c). The Equipment System shall supply power as identified in 3.4.2.2.3.

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

Surveyor asked staff DD, FF, CC, GG to identify Emergency Outlets, receptacles in the Operating Room were not marked as emergency with red covers. Staff could not answer or identify them.

Surveyor asked staff DD, FF, CC, GG to identify two circuits of power in the Operating Room. OR rooms are required to have at least two branches of power, one emergency supplied by the Critical Care Branch, and one from normal power. Staff could not answer the question and indicated that they had not been in-serviced regarding emergency power or normal power.

Surveyor asked staff DD, FF, CC, GG to identify the Lights approximately 6 feet above finish floor in Operating Room 1. Staff could not describe the purpose of the lights and indicated that they had never been in-serviced regarding those lights. Lights located in Operating Room 2 were not functioning (lights in OR 2 were exactly like ones in OR 1). New Receptacles that were not part of original construction (new receptacles were not recessed inside the wall) were installed in both Operating Rooms, neither of the receptacles were provided with Ground Fault Protection.

Surveyor asked for Impedance Ground Testing of Receptacles located in Patient Care Areas, facility could not provide testing report or knew what impedance testing is.

Exhaust fans failed to trip breakers when the fans quit working, the fan motors were too hot to touch. Surveyor noted that Thermal Overloads Supplying the fans were either oversized, or were not provided. NFPA 70 430.31

Based on observation and interview with staff, the Governing Body (in accordance with NFPA 99, 1999 edition, 7-6-2-1) failed to implement, monitor, and report Medical and Surgical electrical instrumentation and monitoring devices, as well as all electric appliances used for the care and entertainment of the patient, purchased or otherwise acquired for use by the facility (e.g., leased, donated constructed on-site, loaned, etc.), shall be required to meet safety performance criteria of 9-2.1, Patient-Care-Related Electrical Appliances, in Chapter 9, "Manufacturer Requirements" of NFPA 99 1999 edition.
Findings:
1. Staff verified the hospital did not have a preventive maintenance program for medical equipment. There was no documentation medical equipment was serviced and repaired as needed.
2. Broken medical equipment (blanket warmer in the medical/surgical area; blanket warmer, fluid warmer, intravenous poles, Bucks traction device, datascope, and acu-rite oven thermometer) was stored with functioning equipment. Staff did not ensure broken equipment was tagged to alert staff not to use it.
3. Staff verified the hospital did not provide training on use of certain medical equipment (i.e. blanket and fluid warmers). There was no documentation that staff received training on medical equipment.
4. Medical equipment was not used according to the manufacturer's instructions. For example, a blanket warmer was set at 150 degrees Fahrenheit and posed a burn hazard to patients. A log for September 2013 documented temperature readings as high as 180 degrees on another blanket warmer. The manufacturer recommended the temperature on the warmer to be set no higher than 120 degrees. Some warmers had no thermometer to monitor internal temperature.
Based on interview with staff, the facility failed to provide education and training with blanket and fluid warmers in the facility to include system demonstration. Any system, electric appliances shall be demonstrated as a complete system after installation by the vendor designated to assume system responsibility, and prior to acceptance of the system by the facility. The vendor shall demonstrate the operation of the system and provide appropriate initial instruction to operators and maintenance personnel.
Findings:
1. Medical equipment was not used according to the manufacturer's instructions. For
example, a blanket warmer was set at 150 degrees Fahrenheit and posed a burn hazard to
patients. A log for September 2013 documented temperature readings as high as 180
degrees on another blanket warmer. The manufacturer recommended the temperature on the
warmer to be set no higher than 120 degrees. Some warmers did not have a thermometer to
monitor internal temperatures.

2. Chief Nursing Officer (CNO) told surveyors, " The blankets were not warm enough on 120 degrees so the blanket warmer was turned up to 150 degrees. The blankets are nice and cozy and none of the patients are getting burned " .
3. On the afternoon of 09/17/13, surveyors observed the temperature knob turned to 150 degrees Fahrenheit. The CNO verified the temperature was set to 150 degrees.