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Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that there were penetrations in the smoke barriers in the following locations: 1) 3rd floor east corridor smoke barrier, 2) 3rd floor central barrier, 3) 3rd floor north corridor, 4) 2nd floor east corridor, 5) 2nd floor north corridor, and 6) 1st floor smoke barrier.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that there were the following issues.

A. There were hazardous areas where there were no closers present. They were: 1) the biohazard room on the 3rd floor., 2) a storage room on the 3rd floor, 3) storage room, 233, on 2nd floor, 4) storage room, 230, on the 2nd floor, 5) the workshop on the 1st floor, and 6) storage in the administration area.

B. The following area was missing both a door and a closer: the small storage closet in the kitchen.

C. The following location required the closure to be adjusted to allow the door to close and latch on its own: the large storage closet in the kitchen.

D. The following location required that the acoustic ceiling be repaired to make the space smoke tight: the paint storage closet on the 3rd floor.

Based on observation the facility failed to provide an adequate stair enclosure.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that there was the following issue with a stair enclosure. The 3rd floor stair in the west corridor did not latch properly. It needed adjustment. Field adjustments were made, but the latch mechanism was still loose.

Based on observation the facility failed to provide adequate clearance under the sprinkler heads.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that there were stored items in the Maintenance Storage Room that were higher than the 18 inch zone below the bottom of the sprinkler head shields.

Storage 18 " below Heads: " A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.


Based on observation the facility failed to properly maintain one of the heads.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that there was a sprinkler head in the administration conference room that did not have an escutcheon plate as required for a listed assembly.

Based on observation the facility failed to provide an adequate bulk oxygen storage area.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that there were dead leaves within the bulk oxygen storage enclosure and that there was a truck parked immediately adjacent to the bulk oxygen enclosure.

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

" Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials. " - NFPA 99, 1999, 4-3.1.1.2(a)5.

In addition, there were tree branches that overhung the bulk oxygen tank enclosure. These are combustible and should be removed.

Emergency Generator Location:
" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observation the facility failed to provide adequate task illumination at the emergency generator.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that there was not a light at the emergency generator with 90 battery backup which was on the life safety branch of the essential electrical system.


Nurse Call System:
Based on observation the facility failed to provide a complete nurse call system as required by CMS and State Regulations.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that the emergency exam room did not have a regular nurse call or a code blue.

The nurse call system shall be in accordance with Table 7 of ?133.169(g). See the following. " A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient's regular calling station will sound a repeating (every 20 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit's nursing station when the call is answered by the nursing staff. The visible signal(s) in the corridor shall be canceled upon termination of the call. Calls shall activate visible signals in accordance with Table 7 of ?133.169(g) of this title. An alarm shall activate at the nurses station when the call cable is unplugged. " - H.L.R., 2007: ?133.162(d)(5)(L)(iii).

A staff emergency assistance calling system (code blue) is intended to be used by staff to summon additional help in an emergency. In open suites, an emergency assistant call system device shall be located at the head of each bed and in each individual room. The emergency assistance calling device can be shared between two beds if conveniently located. Activation of the system will sound a distinct audible signal at the nursing unit's nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. Calls shall activate audible and visible signals in accordance with Table 7 of ?133.169(g) of this title. A visible system shall clearly define the alarm location to a continuously staffed back up area (other than the nurse station or an administrative center) from which assistance can be summoned. Alternatively, back up may be provided via automatic annunciation from the staff emergency assistance calling system through wireless phones or pagers. The system shall have voice communication capability so that the type of emergency or help required may be specified between the point of alarm and the unit's nurse station. " - H.L.R., 2007: ?133.162(d)(5)(L)(iii).


Receptacle Testing in Patient Care Areas
NFFA 99, 1999, 3-3.3.3
(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).

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).

Based on observation the facility failed to provide a history of testing of electrical receptacles per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that the facility had not been conducting required receptacle testing.


Letter re. Emergency Fuel:
NPFA 99, 11-5.3.2.

Based on observation the facility failed to provide a letter from a vendor for emergency fuel indicating that they have a preferred customer status at the time of the inspection.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that the facility did not have a letter from a vendor indicating that they are a preferred customer in the event of an emergency.

Based on observation the facility failed to provide an acceptable location for an alcohol based hand rub dispenser at some locations.

The inspector observed, while accompanied by the Director of Plant Operations during the hours of the inspection from 1:00 pm to 6:00 pm on 8/30/2012 that alcohol based hand rubs were located witin 6 inches of electrical devices in the following locations: 1) 2nd floor medication room, and 2) 2nd floor staff lounge.