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Based on the observation on 7/06/2015, the facility failed to maintain corridor doors to resist the passage of smoke. Findings include:

1. Dining room door failed to positive latch, this door opens into the corridor.

2. Janitor room door failed to positive latch, this door opens into the corridor.
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NFPA 101, 19.3.6.3.1
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Based on the observation on 7/06/2015, the facility failed to provide separation of hazardous area. Findings include:

The combustible storage located by the kitchen, is approximately 192 sq. feet, door failed to positive latch.
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NFPA 101, 19.3.2.1 and 8.4.1
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Based on the review of documentation on 7/6/2015, the facility failed to perform sensitivity testing of smoke detectors. Findings include:

According to documentation provided the last date that sensitivity testing of smoke detectors was conducted was on 7/5/2012.
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Detector sensitivity shall be checked with one year after installation and
every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).
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Based on the observation on 7/6/2015, the facility failed to maintain complete sprinkler coverage. Findings include:

Two ceiling tiles in the large Medical records storage room had holes approximately 1"x 1".
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NFPA 13, 5-6
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Based on observation on 7/6/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. According to documentation, the last date on replacement of gauges on the dry riser was 9/30/2009.

2. Documentation was not provided for the annual partial trip test of the dry riser or the three year full flow trip test.

3. Build up of paint on the deflector of two sprinklers in Patient Room 105.

4. Build up of paint on the deflector of a sprinkler in the Janitor room by the Dining room.

5. Blue wiring attached to the sprinkler branch lines in the Lab.

6. Blue wiring attached to the sprinkler branch lines in the Pharmacy.
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NFPA 25,1998 Edition, 9-5.2.3 A partial flow trip test adequate to move the valve from its seat shall be conducted annually.
NFPA 25, 1998 Edition, 9-4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.
NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
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Based on the observation on 7/6/2015, the facility failed to provide proper height of fire extinguishers. Findings include:

1. The fire extinguisher in the mechanical room was mounted on the wall. The extinguisher was mounted approximately six foot from the floor to the top to the gauge.

2. The fire extinguisher by the Nurses Station was in a cabinet. The extinguisher was approximately six foot from the floor to the top of the of the gauge.
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1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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* Based on the observation on 7/6/2015, the facility failed to provide an HVAC system that meets requirements of the code. Findings include:

Corridors are being used as return air plenum.
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1999 NFPA 90 A, 2-3.11.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.
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Based on the observation on 7/6/2015, the facility was not providing proper heating. Findings include:

A portable electric space heating device was in the Director of Nusring Office.
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NFPA 101, 19.7.8
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Based on the observation on 7/6/2015, the facility failed to provide proper storage of oxygen cylinders. Findings include:

1. One unsecured E oxygen cylinder on the empty side.

2. Ten unsecured H oxygen cylinders on the empty side.

3. One unsecured E oxygen cylinder on the full side.

4. Eight unsecured H oxygen cylinders on the full side.
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1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
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Based on the observation on 7/6/2015, the facility failed to maintain the remote annunciator for the generator. Findings include:

When the generator was placed under load, the remote annunciator panel did not indicate an audible for generator power. An audible was not indicated when the auto switch was placed in the off position. The lamp test was conducted by maintenance before, at which time, the audible did not indicate.
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1999 NFPA 99, 3-6.1.1 Generators shall conform to 3-4.1.1
1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

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. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.
[110: 3-5.5.2]
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A. Based on the observation on 7/6/2015, the facility failed to assure that equipment used for the care of patients, was not plugged into circuit breaker protected power strips. Findings include:

The following is a list of equipment used for the care of a patient that was plugged into a circuit breaker power strip (an extension cord) in the the emergency room.

A defibrillator, nebulizer, vital sign machine, lV pump, patient heart monitor, and suction machine.

The facility is not provided with adequate number of receptacles for appliances in this room.
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Review of 1999 NFPA 70, 400-7 and 400-8, HCFA Transmittal Notice 22-99, and Interpretative Guidelines for
F 0323 Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be placed overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required.
Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas. Precautions needed if power strips are used include: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; and using power strips that are adequate for the number and types of devices used. Overload on any circuit can potentially cause overheating and fire. The use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution of staff or residents.


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B. Based on the observation on 7/6/2015, the facility failed to maintain the electrical equipment. Findings include:

1. Open blanks in two electrical panels in the mechanical room.

2. Extension cord in use to power the bed in Patient Room 109.

3. A six way adapter was plugged into a two outlet electrical plug in Patient Room 109.

4. A microwave was plugged into a surge protector (extension cord) in the Employee Break Room.

5. A microwave was plugged into a surge protector (extension cord) in the Pharmacy.
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1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99. The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. lt is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, microwaves, or heating units are connected to the power strip.
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