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The inspector observed, while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations, during the hours of the inspection from 9:30 am and 11:00 am, that the facility failed to meet the standard by allowing the door to the dialysis storage room to be held open with a chock under the door.

Based on observation the facility failed to maintain the fire resistance rating of a smoke barrier.

The inspector observed while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations, during the hours of the inspection from 9:30 am and 11:00 am the ancillary space around a penetrating duct was not sealed. This condition was located in the interstitial space outside the second floor nurse station.

Based on observation the facility failed to provide an acceptable fire escape route in the stair to the first floor.

The inspector observed while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations, during the hours of the inspection from 9:30 am to 11:00 am, that the door at the top of the stair at the ICU wing and the north stair required adjustment to close and latch and the north door was difficult to open.

During the hours of 9:30am and 11:00, review of the records indicated the requirement is not met.

Findings: Based on observation, during the hours of inspection between 9:30 am and 11:00 am, accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations the fire drill logs were reviewed. The facility has two shifts, day and night. Two drills were held in the first quarter, but were both on the day shift. No records for a night shift drill during the first quarter was found.

Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations, during the hours of the inspection from 9:30 am and 11:00 am, that there was not cross referencing of the fire alarm control panel and the panel and breaker supplying power. The fire alarm control panel must have a label indicating the panel and breaker supplying power.

Based on observation the facility failed to provide an acceptable fire extinguisher in the Kitchen.

The inspector observed while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of the inspection from 9:30 am to 11:00 am that there was an expired inspection sticker on the fire extinguisher and it indicated it was due a hydrostatic test.

Based on observation the facility failed to provide mater alarm system required by NFPA 99, 1999, 4-3.1.2.2 ( b) 2.

The Standard: The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location)

The Findings: The inspector observed, while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of the inspection from 9:30 am to 11:00 am that no master medical gas alarm was located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems.

A. Based on observation the facility failed to provide an acceptable electrical system in accordance to NFPA 99; 3-4.2.2.2

The Standard: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Findings: The inspector observed while accompanied by the hospital's East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of inspection from 9:30 am to 11:00 am that there were multiple problems with the EES that must be changed. These include: 1) a circuit for a louver was located on the life safety panel; 2) Receptacles are located on the life safety panel; 3) the automatic exit doors were not located ont he life safety panel.

B. Based on observation the facility did not meet the requirement of NFPA 99 3-4.1.1.1.

The Standard: A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station .. .Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location.

The Findings: The inspector observed while accompanied by the hospital's East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of inspection from 9:30 am to 11:00 am that there was not an alarm in a readily observable location by operating personnel at a regular work station

A. The inspector observed while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of the inspection from 9:30 am to 11:00 am that receptacle testing in patient care areas was not being done on a regular basis.

The Standard: NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. If the facility has documented performance data for the electrical receptacles in all patient care areas then the schedule defined by this data will be acceptable. In the absence of the data the following schedule shall be maintained by the facility. Receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

The following is a description of NFFA 99, 1999, 3-3.3.3 Receptacle Testing in Patient Care Areas:
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

B. The inspector observed while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of the inspection from 9:30 am to 11:00 am that the requirement of NFPA 99: 11-5.3.9 was not met.

The Standard: Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilites with emergency services, disaster receiving stations, or both.

Findings: The disaster drill log and after action reports for the hospital Disaster Drills were not being kept on site. The after action report that was sent over to the East Group Director of Plant Operations was for another campus not the campus being surveyed.

C. Based on observation the facility failed to provide acceptable line isolation monitors and testing.

The Standard: The monitor shall be designed such that a green signal lamp, conspicuously visible to persons in the anesthetizing location, remains lighted when the system is adequately isolated from ground, and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions - NFPA 99, 1999, 3-3.2.2.3(b)
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Findings: The inspector observed while accompanied by the East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of the inspection from 9:30 am to 11:00 am that the line isolation monitors where outside of the operating rooms. No testing records were found.

Based on observation the facility failed to provide acceptable electrical wiring and equipment in accordance with NFPA 70, the National Electrical Code.

The Standard: Each box shall have a cover, faceplate of fixture canopy.of any nature are required to have properly secured cover plates with all wiring secured inside. - 1999 NFPA 70: 370-25

The Findings: The inspector observed while accompanied by the hospital's East Group Director of Plant Operations and the Supervisor of Plant Operations during the hours of the inspection from 9:30 am to 11:00 am that there was a problem with wiring. A j-box in the interstitial space on the ICU side of the fire barrier wall was not secured closed.