HospitalInspections.org

Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could affect all of the occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06/10/19 at approximately 3:41 PM, while performing a visual inspection of the function of the door to Housekeeping room 133, it was observed that the latch for the door would not engage in the strike plate, assuring the door remained latched when closed. This finding was confirmed by interview and observation by employee D at the time of discovery.

2. On 06/10/19 at approximately 3:02 PM, while performing a visual inspection of the function of the door to the linen room on the first floor, it was observed that the latch for the door would not engage in the strike plate, assuring the door remained latched when closed. This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon observation and interview, the facility failed to ensure that the means of egress is illuminated in accordance with 7.8 as required by 19.2.8. This deficient practice could affect all of the occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06/10/19 at approximately 2:24 PM while performing a visual inspection of the emergency lighting for the exterior exit pathway from the marked exit door by the dietary office, it was observed that there was only one source of emergency lighting in this area. This finding was confirmed by interview and observation by employee D at the time of discovery.

2. On 06/10/19 at approximately 2:45 PM while performing a visual inspection of the emergency lighting for the exterior exit pathway from the marked exit door from stairwell D, it was observed that there was only one source of emergency lighting in this area. This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon observation, records review and interview, the facility failed to ensure that building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99 as required by NFPA 99 Chapter 4. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06-10-19 at 11:26 AM during a review of records for the required annual inspection of fire and smoke barrier doors, it was revealed that there were multiple doors that had not passed the annual safety inspection, per a 3rd party inspection company. The report revealed that of the 34 doors inspected, 7 had issues that had not been repaired as of this inspection. This finding was confirmed by interview with employee D at the time of discovery.

2. On 06/10/19 at 1:04 PM during a review of records for Smoke Dampers, it was revealed from the record entitled Testing of Fire and Smoke Dampers, dated 09-20-16, that 2 of the 104 smoke dampers had failed the inspection and had not been repaired as of this inspection. This finding was confirmed by interview with employee D at the time of inspection.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect all of the occupants in the event of a smoke or fire emergency.

Findings Include:
On 06/10/19 at approximately 2:14 PM while performing a visual inspection of the janitors closet in the kitchen, it was observed that there was a 2 1/2 inch gray plastic conduit with a black cable inside it penetrating the 1 hour fire rated wall. Around this conduit was an unknown type of white caulking material. According to employee D, it was uncertain if this was a fire rated caulking material or not. This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon interview, the facility failed to ensure that cooking facilities are protected in accordance with NFPA 96 unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.4.4 as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, and TIA 12-2. This deficient practice could affect all of the occupants in the event of a fire emergency

Findings Include:
On 06/10/19 at approximately 2:12 PM, while interviewing employee BB, it was learned through questioning, that this employee was not familiar with the proper procedures on what to do in the event of an appliance fire. When asked what they would do in the event of an appliance fire, the employee stated first they would "pull the fire alarm and then get a fire extinguisher". The first step in the event of an appliance fire is to activate the ansul station (fire protection equipment for appliances). This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon observation, and interview, the facility failed to ensure that Alcohol Based Hand Rub dispensers are protected in accordance with 8.7.3.1 unless meeting all conditions as required by 19.3.2.6 and 42 CFR Parts 403, 418, 460, 482, 483, and 485. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
On 06/10/19 at approximately 4:07 PM while performing a visual inspection of the Alcohol Based Hand Rub dispensers in the emergency room triage area, it was observed that a dispenser had been mounted on the wall directly above an electrical outlet. This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect all of the occupants in the event of a fire emergency.

Findings Include:
1. On 06/10/19 at approximately 1:39 PM, while conducting a visual inspection of the sprinkler piping above the ceiling in the lower level by door 041, it was observed that there was a 1/2 inch gray electrical conduit clamped to and was being supported by the sprinkler pipe. Sprinkler systems must be stand alone and attachments are not permitted. This finding was confirmed by observation and interview by employee D at the time of discovery.

2. On 06/10/19 at approximately 2:33 PM, while conducting a visual inspection of the sprinkler piping above the ceiling by the kitchen store room by electrical panel L, it was observed that there was a gray wire attached to and was being supported by the sprinkler pipe. This finding was confirmed by observation and interview by employee D at the time of discovery.

3. On 06/10/19 at approximately 3:27 PM, while conducting a visual inspection of the sprinkler piping above the ceiling near room 110, it was observed that there was a black cable wire-tied to and was being supported by the sprinkler pipe support bracket. This finding was confirmed by observation and interview by employee D at the time of discovery.

Based upon observation, and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 6/10/19 at approximately 3:30 PM while performing a visual and function test of the corridor door to patient care room 110, it was observed that the door would not latch when closed. This finding was confirmed by interview and observation by employee D at the time of discovery.

2. On 6/10/19 at approximately 3:35 PM while performing a visual and function test of the corridor door to patient care room 109, it was observed that when closed and latched, the gap at the top of the door where it met with the doors frame was greater than 1/8th of an inch. This finding was confirmed by interview and observation by employee D at the time discovery.

3. On 6/10/19 at approximately 3:36 PM while performing a visual and function test of the corridor door to patient care room 107, it was observed that when closed and latched, the gap at the top of the door where it met with the doors frame was greater than 1/8th of an inch. This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon observation, and interview, the facility failed to ensure that portable space heating devices were used only in non-sleeping staff and employee areas as required by 19.7.8. This deficient practice could affect all of the occupants in the event of a smoke or fire emergency.

Findings Include:
On 06/10/19 at approximately 2:53 PM, while performing a visual inspection in the Human Resources office, it was observed that a portable space heater was in this space and not an approved type. Upon testing of this space heater by turning it on with the heat portion activated, it was observed that it did not have tip over protection or a automatic shut off feature when layed on its back. This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon record review and interview, the facility failed to ensure that generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4, and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect all occupants in the event of smoke or fire emergency where there was a loss of main utility power.

Findings Include:
On 06/10/19 at approximately 12:30 PM during a review of records for the emergency generator monthly run test, it was revealed that the records did not consistently reflect which Automatic Transfer Switch was being used to perform the simulated power loss. This finding was confirmed by interview with employee D at the time of discovery.

Based upon observation and interview, the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect all occupants in the event of smoke or fire emergency.

Findings Include:
1. On 06/10/19 at approximately 3:22 PM while performing a visual inspection of electrical equipment in the med supply room, it was observed that there were 2 refrigerators plugged into a multi plug power strip. This finding was confirmed by interview and observation by employee D at the time of discovery.

Based upon observation and interview, the facility failed to ensure that all patient-care related electrical equipment is tested and maintained as required by 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, and 10.5.8 of NFPA 99. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
On 06/10/19 at approximately 4:18 PM while performing a visual inspection of electrical equipment in electrical room E-18, it was observed that there was a piece of electrical equipment sitting on the floor with its protective cover missing, exposing electrical wires to casual contact. This finding was confirmed by interview and observation by employee D at the time of discovery.