HospitalInspections.org

Based on observation it was determined the facility failed to ensure corridor doors were provided with positive latching hardware. Findings:

On 12/09/15 at 3:02 p.m., it was observed the double doors to the mammography room were held open with two wooden wedges. It was also observed these doors had no positive latching hardware.

At 4:24 p.m., it was observed the double doors to radiology had no positive latching hardware.

On 12/10/15 at 11:10 a.m., it was observed the housekeeking room labeled H-3 did not have positive latching hardware.

The plant operations manager acknowledged the doors being held open by wooden chocks, and there was no positive latching hardware on each.

Based on observation it was determined the facility failed to ensure exits were marked by approved, readily visible signs in all cases where the exit or way to reach an exit is not readily apparent to the occupants and doors, passages, or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit". Findings:

On 12/10/15 at 11:26 a.m., an exit door leading outside was blocked by a potted plant. There was an exit sign illuminated from the ceiling and a horizontal yellow sign with black letters affixed to the panic bar of the exit door had "DO NOT ENTER" written on it.

The physical plant manager was asked about this exits' designation. He said the plant should not be blocking the exit, and the sign indicating do not enter should be on the outside of the door. He stated staff and visitors can exit from the door but it is locked on the outside where no one can use it as an entrance into the facility.

On 12/10/15 at 11:33 a.m., an outdoor courtyard was observed with double doors leading outside from the corridor did not have signage indicating it was or was not an exit.

The physical plant manager was asked about the double doors leading to an outside courtyard. He said it was not an exit and it was an enclosed courtyard with no other exit once in the courtyard. He acknowledged there was no signage indicating it was or was not an exit.

18.2.10 Marking of Means of Egress.
18.2.10.1
Means of egress shall have signs in accordance with Section 7.10.

7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required.
Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.3 Exit Stair Door Tactile Signage.
Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows:
EXIT
Signage shall comply with CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door 60 in. (152 cm) above the finished floor to the centerline of the sign.
Exception: This requirement shall not apply to existing buildings, provided that the occupancy classification does not change.
7.10.1.4* Exit Access.
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.
7.10.1.5* Floor Proximity Exit Signs.
Where floor proximity exit signs are required in Chapters 11 through 42, signs shall be placed near the floor level in addition to those signs required for doors or corridors. These signs shall be illuminated in accordance with 7.10.5. Externally illuminated signs shall be sized in accordance with 7.10.6.1. The bottom of the sign shall be not less than 6 in. (15.2 cm) but not more than 8 in. (20.3 cm) above the floor. For exit doors, the sign shall be mounted on the door or adjacent to the door with the nearest edge of the sign within 4 in. (10.2 cm) of the door frame.
7.10.1.6* Floor Proximity Egress Path Marking.
Where floor proximity egress path marking is required in Chapters 11 through 42, a listed and approved floor proximity egress path marking system that is internally illuminated shall be installed within 8 in. (20.3 cm) of the floor. The system shall provide a visible delineation of the path of travel along the designated exit access and shall be essentially continuous, except as interrupted by doorways, hallways, corridors, or other such architectural features. The system shall operate continuously or at any time the building fire alarm system is activated. The activation, duration, and continuity of operation of the system shall be in accordance with 7.9.2.
7.10.1.7* Visibility.
Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
7.10.3* Sign Legend.
Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.
7.10.4* Power Source.
Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.
7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
7.10.5.2* Continuous Illumination.
Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception*: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.
7.10.6 Externally Illuminated Signs.
7.10.6.1* Size of Signs.
Externally illuminated signs required by 7.10.1 and 7.10.2, other than approved existing signs, shall have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in. (5 cm), except the letter I, and the minimum spacing between letters shall be not less than 3/8 in. (1 cm). Signs larger than the minimum established in this paragraph shall have letter widths, strokes, and spacing in proportion to their height.
Exception No. 1: This requirement shall not apply to existing signs having the required wording in plainly legible letters not less than 4 in. (10.2 cm) high.
Exception No. 2: This requirement shall not apply to marking required by 7.10.1.3 and 7.10.1.5.
7.10.6.2* Size and Location of Directional Indicator.
The directional indicator shall be located outside of the EXIT legend, not less than 3/8 in. (1 cm) from any letter. The directional indicator shall be of a chevron type, as shown in Figure 7.10.6.2. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft (12.2 m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.
Exception: This requirement shall not apply to approved existing signs.
Figure 7.10.6.2 Chevron-type indicator.

7.10.6.3* Level of Illumination.
Externally illuminated signs shall be illuminated by not less than 5 ft-candles (54 lux) at the illuminated surface and shall have a contrast ratio of not less than 0.5.
7.10.7 Internally Illuminated Signs.
7.10.7.1 Listing.
Internally illuminated signs, other than approved existing signs, or existing signs having the required wording in legible letters not less than 4 in. (10.2 cm) high, shall be listed in accordance with UL 924, Standard for Safety Emergency Lighting and Power Equipment.
Exception: This requirement shall not apply to signs that are in accordance with 7.10.1.3 and 7.10.1.5.
7.10.7.2* Photoluminescent Signs.
The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source as determined by the authority having jurisdiction. The charging light source shall be of a type specified in the product markings.

7.10.8 Special Signs.
7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on observation it was determined the facility failed to ensure hazardous areas were protected. Findings:

On 12/09/15 at 3:40 p.m., mechanical room #2 near the emergency room was observed to have 8 penetrations in the fire wall.

At 4:15 p.m., electrical room #5 was observed to have combustible items stored within it. The items stored in the electrical room were observed to be 5 cardboard boxes filled with wiring supplies, 7 wooden frame pictures, and 2 plastic slippery when wet signs.

On 12/10/15 at 9:29 a.m., the janitor closet did not have self closing hardware.

At 9:58 a.m., mechanical room #3 near the operating room was observed to have 10 penetrations and did not have self-closing hardware on the doors.

At 11:19 a.m., mechanical room #14 was observed to have 2 penetrations in the fire wall.

At 11:35 a.m., mechanical room #6 in physical therapy was observed to not have self closing hardware on the doors.

The plant operations manager acknowledged each of the mechanical rooms with penetrations and with no self-closing hardware.

Based on observation it was determined the facility failed to ensure egress doors had a releasing mechanism that could be opened with not more than one releasing operation. Findings:

On 12/09/15 at 3:12 p.m., a deadbolt lock was observed to be on the radiology office door.

At 4:40 p.m., a 5 push pin lock was on the egress exit door within the psychiatric geriatric department.

The 3 staff on duty at the time within the psychiatric geriatric department was asked if they knew the 5 push pin code to exit in case of an emergency. Each of the 3 facility staff stated they did not know or have the code to that exit door.

On 12/10/15 at 10:24 a.m., a deadbolt lock was observed to be on the pharmacy storage room.

At 11:39 a.m., a deadbolt lock was observed to be on the exit door in the physical therapy department.

NFPA 101, 2000 Edition
Chapter 7
7.2.1.5.10
A latch or other fastening device on a door leaf shall be provided with a releasing device that has an "obvious method of operation" and that is "readily operated" under all lighting conditions.
7.2.1.5.10.2
The releasing mechanism "shall open the door leaf with not more than one releasing operation."

Based on observation it was determined the facility failed to ensure all exit discharge areas were provided with emergency backed up lighting. Findings:

On 12/09/15 at 2:38 p.m., it was observed at the outpatient registration exit was not equipped with emergency backup lighting at the exit discharge to the public way.

The plant operations manager acknowledged the exit with no emergency lighting from exit discharge to the public way.

NFPA 101, 2000 Edition, Chapter 19
19.2.9 Emergency Lighting.
19.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9.

NFPA 101, 2000 Edition, Chapter 7
7.9 EMERGENCY LIGHTING
7.9.1 General.
7.9.1.1*
Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

Based on observation it was determined the facility failed to ensure their vertical opening was protected with smoke detection. Findings:
On 12/09/15 at 2:50 p.m., the vertical opening near the kitchen was observed to not be protected with smoke detection devices.
At 2:51 p.m., the physical plant manager acknowledged the absence of smoke detection at the ceiling of the vertical opening near the kitchen.
On 12/21/15 at 1:38 p.m., the CMS Region VI LSC Engineer was called for guidance and clarification regarding the vertical opening at EOMC not having smoke detection. He advised the area needed to be protected with smoke detection devices.
9.6 FIRE DETECTION, ALARM, AND COMMUNICATIONS SYSTEMS
9.6.1 General.
9.6.1.1
The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2
Fire detection, alarm, and communications systems installed to make use of an alternative allowed by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.
9.6.1.3*
The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

Based on observation and staff interview the facility failed to ensure air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations. Findings:

On 12/10/15 at 9:59 a.m., the operating rooms air filter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.

At 10:00 a.m., the physical plant manager was interviewed. The physical plant manager was asked for the documentation of airflow quality for the operating rooms. He said the HVAC filters that serve the operating rooms are changed on observation and periodically. He was asked if there were any manometers downstream to the HVAC that serve each of the operating rooms and the procedure room within their surgical suite. He said no.

At 3:32 a.m., the biohazard/dirty room was not mechanically vented with negative airflow.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.

Based on observation it was determined the facility failed to ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:

On 12/09/15 at 11:17 a.m., a four wheeled pallet cart with desks on it was stored within the exit corridor near the physical plant maintenance room.

At 11:44 a.m., the second egress exit located in the biomedical office was blocked with assorted items.

At 4:30 p.m., the four wheeled pallet cart with desks on it was observed to be within the exit corridor near the physical plant maintenance room.

7.1.10 Means of Egress Reliability.
7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation it was determined the facility failed to ensure the Type I EES was divided into critical branch, and life safety branch. Findings:

On 12/09/15 at 12:15 p.m., it was observed the facility had multiple electrical panels throughout the facility. None of the electrical panels inspected were labeled life safety branch and/or critical branch. On inspection of the contents of the electrical panels throughout the facility it was observed the components of the LSC branch panel were mixed with the critical branch panel components. The life safety code and critical branch electrical breaker panels were not identified.

The plant operations manager acknowledged the life safety branch and critical branch could not be indentified along with their specific components for each not being identified.

NFPA 99, 1999 Edition, Chapter 3 Electrical Systems
3-4.2.2 Specific Requirements.
3-4.2.2.1* General.
Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation.
Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

NFPA 99, 1999 Edition,
Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. 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.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Based on observation it was determined the facility failed to ensure all electrical wiring and equipment are in accordance with the code standards of compliance. Findings:

On 12/09/15 at 3:22 p.m., 2 extension cords were observed to be in use at the emergency room reception area.

On 12/10/15 at 11:36 a.m., there were 2 hydroculators observed to be plugged into a non-GFCI receptacle in the physical therapy department.

The physical plant manager acknowledged the 2 extension cords being used in the emergency room reception area and also saw the 2 hydroculators plugged into a non-GFCI receptacle.

National Electrical Code, NFPA 70, NFPA 99, NFPA 101, 2000 Edition.

Based on observation it was determined the facility failed to ensure alcohol based hand rub dispensers were not installed over an ignition source. Findings:

On 12/09/15 at 3:50 p.m., it was observed in ICU room #8 an alcohol based hand rub was installed over an electrical outlet.

On 12/10/15 10:22 a.m., it was observed in the PACU an alcohol based hand rub was installed over a light switch.

At 10:48 a.m., it was observed in the emergency room doctor's lounge an alcohol based hand rub dispenser installed over an electrical receptacle.

The plant operations manager acknowledged the ABHR dispensers installed over ignition sources.

NFPA 101, 2000 Edition, 18.3.2.7
CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623