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Based upon observation and interview on August 20 & 21, 2014 the facility failed to ensure exit access and exit discharge was unobstructed and immediately accessible to a public way. Failure to provide accessible means of egress exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons.

Findings include:

1) During the initial building tour on August 20, 2014 and then again during the detailed tour of the building on August 21, 2014 observation revealed the storage of a Portable X-ray device and two wheelchairs stored in the corridor between the OR suite and the ED suite. When asked if that was where they were normally stored the Facilities Director confirmed this and added that the emergency plan called for them to be immediately moved in an emergency.

2) During the facility tour on August 20 & 21, 2014 observation revealed the hard surfaced exit discharge from the surgical patient wing did not connect to a public way or parking area, there was approximately 50 feet of grassy surface to cross before a hard surface area was available. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the Facilities Director during the exit interview. When asked if the grassy area was cleared of snow during inclement weather, the Facilities Director stated it was not a part of their snow removal plan.

3) During the facility tour on August 20 & 21, 2014 observation of the ultrasound room and Clean Linen revealed deadbolt locks located in a required means of egress door, which could require a secondary action to open and pass through the exit access.

Actual NFPA Standard:

1 & 2)
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

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.

3) 7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Based upon observation and interview on August 20 & 21, 2014, the facility failed to ensure adequate discharge lighting at the surgical wing exit. This deficient practice can hinder rapid evacuation and dispersal in an evacuation. The facility is licensed for 25 beds and had a census of five on the date of the entrance conference.

Findings include:

During the facility tour on August 20 & 21, 2014, observation revealed the exit discharge from the surgical wing was illuminated by a single bulb light fixture. Interview with Facilities Director revealed he was unaware of the requirement for redundant lighting.

Actual NFPA standard:

NFPA 101 - 2000

7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. 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, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

Based upon observation the facility failed to ensure electronic supervision of the sprinkler controls. Lack of supervision could allow for disabling the sprinkler system without the facility's knowledge, this deficient practice could put all patients, staff and visitors at risk. The facility is licensed for 25 beds and had a census of five on the entrance date of the survey.

Findings include:

During the facility tour on August 20, 2014 between 1:00 PM and 5:00 PM the water supply valve to the sprinkler system main riser and the antifreeze loop water supply control valves were observed to be locked with a chain and padlock, but not electronically supervised. The Post Indicator Valve was the only sprinkler system valve that was electronically supervised.

Actual NFPA standard:

101-2000
9.7.2.1* Supervisory Signals.
Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Based upon record review and interview the facility failed to test and maintain the automatic sprinkler system in a reliable operating condition in accordance with NFPA 25. This deficient practice could result in the system not fully functional during an emergency, this practice affected all patients and staff present on the day of the survey. The facility is licensed for 25 and had a census of five on the day of the survey.

Findings include:

During record review on August 20, 2014 of sprinkler testing documentation, the latest (August 1, 2014) annual report indicated the five year internal obstruction investigation is due.


Actual NFPA Standard:

NFPA 25, 1999 Edition

10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

A-10-2 (informational only)
For effective control and extinguishment of fire, automatic sprinklers should receive an unobstructed flow of water. Although the overall performance record of automatic sprinklers has been very satisfactory, there have been numerous instances of impaired efficiency because sprinkler piping or sprinklers were plugged with pipe scale, mud, stones, or other foreign material. If the first sprinklers to open in a fire are plugged, the fire in that area cannot be extinguished or controlled by prewetting of adjacent combustibles. In such a situation, the fire can grow to an uncontrollable size, resulting in greater fire damage and excessive sprinkler operation and even threatening the structural integrity of the building, depending on the number of plugged sprinklers and fire severity.
Keeping the inside of sprinkler system piping free of scale, silt, or other obstructing material is an integral part of an effective loss prevention program.

Based upon observation and interview the facility failed to ensure proper emergency lighting in anesthetizing locations. This deficient practice could result in a surgical procedure being compromised by darkness. The facility is licensed for 25 beds and had a census of five on the date of the entrance conference.

Findings include:

During the facility tour on August 21, 2014 observation revealed a lack of battery operated lighting provided in Operating Rooms #1 or # 2. When asked if any of the fixed lighting fixtures in the room were battery powered the facilities director stated not to his knowledge.


Actual NFPA standard:

NFPA 99-1999

3-3.2.1.2(a)5.e. Wiring in Anesthetizing Locations. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based upon observation and staff interview on August 20 & 21, 2014, the facility failed to ensure adequate electrical safety in accordance with NFPA 70. Failure to provide electrical safety could result in injuries or death. The facility is licensed for 25 beds and had a census of five on the day of the survey.

Findings include:

1) During the facility tour on August 20 & 21, 2014 observation revealed two (2) relocatable power taps (RPT's) being used to power patient care equipment in OR #1, one powering the endoscopy equipment cart, the other being used as an extension cord to power the secondary endoscopy screen.

2) During the facility tour on August 20 & 21, 2014 observation revealed relocatable power taps (RPT's) being used with significant startup loads including refrigerators in employee break room, clean linen storage room, and the OR office.

Interview with the maintenance engineer revealed he was not aware that RPT's were not listed for this type of use.

3) During the facility tour on August 21, 2014 observation revealed a duplex outlet located within 6 feet of the emergency shower in the laboratory, when tested the duplex outlet was confirmed to not be GFCI protected.

Actual NFPA reference:

NFPA 101 the Life Safety Code
9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, National Electrical Code, 1999 Edition

NFPA 70 - 110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

See UL listing 1363 and UL XBYS.GuideInfo Relocatable Power Taps

NEC/NFPA 70 - 1999
550.13
(B) Ground-Fault Circuit Interrupters (GFCI). All 125-volt, single-phase, 15- and 20-ampere receptacle outlets installed outdoors, in compartments accessible from outside the unit, or in bathrooms, including receptacles in luminaries (light fixtures), shall have GFCI protection for personnel. GFCI protection for personnel shall be provided for receptacle outlets serving countertops in kitchens, and receptacle outlets located within 1.8 am (6 ft) of a wet bar sink.
Exception: Receptacles installed for appliances in dedicated spaces, such as for dishwashers, disposals, refrigerators, freezers, and laundry equipment.
Feeders supplying branch circuits shall be permitted to be protected by a ground-fault circuit-interrupter in lieu of the provision for such interrupters specified herein.

Based upon observation and interview on August 20 & 21, 2014 the facility failed to ensure exit access and exit discharge was unobstructed and immediately accessible to a public way. Failure to provide accessible means of egress exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons.

Findings include:

1) During the initial building tour on August 20, 2014 and then again during the detailed tour of the building on August 21, 2014 observation revealed the storage of a Portable X-ray device and two wheelchairs stored in the corridor between the OR suite and the ED suite. When asked if that was where they were normally stored the Facilities Director confirmed this and added that the emergency plan called for them to be immediately moved in an emergency.

2) During the facility tour on August 20 & 21, 2014 observation revealed the hard surfaced exit discharge from the surgical patient wing did not connect to a public way or parking area, there was approximately 50 feet of grassy surface to cross before a hard surface area was available. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the Facilities Director during the exit interview. When asked if the grassy area was cleared of snow during inclement weather, the Facilities Director stated it was not a part of their snow removal plan.

3) During the facility tour on August 20 & 21, 2014 observation of the ultrasound room and Clean Linen revealed deadbolt locks located in a required means of egress door, which could require a secondary action to open and pass through the exit access.

Actual NFPA Standard:

1 & 2)
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

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.

3) 7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Based upon observation and interview on August 20 & 21, 2014, the facility failed to ensure adequate discharge lighting at the surgical wing exit. This deficient practice can hinder rapid evacuation and dispersal in an evacuation. The facility is licensed for 25 beds and had a census of five on the date of the entrance conference.

Findings include:

During the facility tour on August 20 & 21, 2014, observation revealed the exit discharge from the surgical wing was illuminated by a single bulb light fixture. Interview with Facilities Director revealed he was unaware of the requirement for redundant lighting.

Actual NFPA standard:

NFPA 101 - 2000

7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. 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, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

Based upon observation the facility failed to ensure electronic supervision of the sprinkler controls. Lack of supervision could allow for disabling the sprinkler system without the facility's knowledge, this deficient practice could put all patients, staff and visitors at risk. The facility is licensed for 25 beds and had a census of five on the entrance date of the survey.

Findings include:

During the facility tour on August 20, 2014 between 1:00 PM and 5:00 PM the water supply valve to the sprinkler system main riser and the antifreeze loop water supply control valves were observed to be locked with a chain and padlock, but not electronically supervised. The Post Indicator Valve was the only sprinkler system valve that was electronically supervised.

Actual NFPA standard:

101-2000
9.7.2.1* Supervisory Signals.
Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Based upon record review and interview the facility failed to test and maintain the automatic sprinkler system in a reliable operating condition in accordance with NFPA 25. This deficient practice could result in the system not fully functional during an emergency, this practice affected all patients and staff present on the day of the survey. The facility is licensed for 25 and had a census of five on the day of the survey.

Findings include:

During record review on August 20, 2014 of sprinkler testing documentation, the latest (August 1, 2014) annual report indicated the five year internal obstruction investigation is due.


Actual NFPA Standard:

NFPA 25, 1999 Edition

10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

A-10-2 (informational only)
For effective control and extinguishment of fire, automatic sprinklers should receive an unobstructed flow of water. Although the overall performance record of automatic sprinklers has been very satisfactory, there have been numerous instances of impaired efficiency because sprinkler piping or sprinklers were plugged with pipe scale, mud, stones, or other foreign material. If the first sprinklers to open in a fire are plugged, the fire in that area cannot be extinguished or controlled by prewetting of adjacent combustibles. In such a situation, the fire can grow to an uncontrollable size, resulting in greater fire damage and excessive sprinkler operation and even threatening the structural integrity of the building, depending on the number of plugged sprinklers and fire severity.
Keeping the inside of sprinkler system piping free of scale, silt, or other obstructing material is an integral part of an effective loss prevention program.

Based upon observation and interview the facility failed to ensure proper emergency lighting in anesthetizing locations. This deficient practice could result in a surgical procedure being compromised by darkness. The facility is licensed for 25 beds and had a census of five on the date of the entrance conference.

Findings include:

During the facility tour on August 21, 2014 observation revealed a lack of battery operated lighting provided in Operating Rooms #1 or # 2. When asked if any of the fixed lighting fixtures in the room were battery powered the facilities director stated not to his knowledge.


Actual NFPA standard:

NFPA 99-1999

3-3.2.1.2(a)5.e. Wiring in Anesthetizing Locations. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based upon observation and staff interview on August 20 & 21, 2014, the facility failed to ensure adequate electrical safety in accordance with NFPA 70. Failure to provide electrical safety could result in injuries or death. The facility is licensed for 25 beds and had a census of five on the day of the survey.

Findings include:

1) During the facility tour on August 20 & 21, 2014 observation revealed two (2) relocatable power taps (RPT's) being used to power patient care equipment in OR #1, one powering the endoscopy equipment cart, the other being used as an extension cord to power the secondary endoscopy screen.

2) During the facility tour on August 20 & 21, 2014 observation revealed relocatable power taps (RPT's) being used with significant startup loads including refrigerators in employee break room, clean linen storage room, and the OR office.

Interview with the maintenance engineer revealed he was not aware that RPT's were not listed for this type of use.

3) During the facility tour on August 21, 2014 observation revealed a duplex outlet located within 6 feet of the emergency shower in the laboratory, when tested the duplex outlet was confirmed to not be GFCI protected.

Actual NFPA reference:

NFPA 101 the Life Safety Code
9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. NFPA 70, National Electrical Code, 1999 Edition

NFPA 70 - 110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

See UL listing 1363 and UL XBYS.GuideInfo Relocatable Power Taps

NEC/NFPA 70 - 1999
550.13
(B) Ground-Fault Circuit Interrupters (GFCI). All 125-volt, single-phase, 15- and 20-ampere receptacle outlets installed outdoors, in compartments accessible from outside the unit, or in bathrooms, including receptacles in luminaries (light fixtures), shall have GFCI protection for personnel. GFCI protection for personnel shall be provided for receptacle outlets serving countertops in kitchens, and receptacle outlets located within 1.8 am (6 ft) of a wet bar sink.
Exception: Receptacles installed for appliances in dedicated spaces, such as for dishwashers, disposals, refrigerators, freezers, and laundry equipment.
Feeders supplying branch circuits shall be permitted to be protected by a ground-fault circuit-interrupter in lieu of the provision for such interrupters specified herein.