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Based on observation and interview, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This affected two of two smoke compartments and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 5/16/12 to 5/17/12, the walls and ceilings were observed.

May 16, 2012 -
1. At 2:56 p.m., there was an approximately 1/2 inch penetration around a closed drain pipe, an approximately 1/4 inch penetration around a copper pipe, and an approximately 3 inch round penetration, in the front wall of the lobby, behind the water cooler.

During an interview at 2:56 p.m., Maintenance Staff 1 stated that the pipes used to be connected to a sink that was removed more than one year ago.

2. At 3:16 p.m., there was an approximately 1 inch round penetration in the ceiling of the surgery department sterilization room.

3. At 3:18 p.m., there was an approximately 1 1/2 inch penetration in the wall of the surgery department wrapping room, behind the autoclave machine.

May 17, 2012 -
4. At 9:04 a.m., there was an approximately 1 1/4 inch penetration, around a wire conduit and two cables, in the ceiling of the laboratory, near the work bench.

5. At 9:13 a.m., there was an approximately 1/2 inch penetration around an escutcheon ring in the ceiling of the mammogram room.

6. At 9:25 a.m., there was an approximately 1/2 inch penetration around an escutcheon ring near the emergency department reception desk.

7. At 11:22 a.m., there were two approximately 3 inch circular penetrations in the ceiling of the chief nursing officer's office.

Based on observation, the facility failed to maintain their corridor doors, as evidenced by doors that were obstructed from closing, and by doors that failed to latch. This affected two of two smoke compartments and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

During a facility tour with staff from 5/16/12 to 5/17/12, the corridor doors were observed.

May 16, 2012 -
1. At 2:59 p.m., the door into the lobby was equipped with a self-closing device. The door closed but failed to latch.

2. At 3:05 p.m., the door to the IT closet was equipped with a self-closing device. The door closed but failed to latch.

3. At 3:46 p.m., the door to the recovery room was equipped with a self-closing device. The door closed but failed to latch.

4. At 4:21 p.m., on 5/16/12, and at 10:39 a.m., on 5/17/12, the door to the physical therapy room was equipped with a self-closing device. The door was held open by a kick-type device that obstructed the door from closing.

5. 2. At 4:31 p.m., the door to the dining room was equipped with a self-closing device. The door closed but failed to latch.

May 17, 2012 -
6. At 8:19 a.m., the door to the admitting office was equipped with a self-closing device. The door closed but failed to latch.

7. At 8:59 a.m., the door to the janitorial closet, across from the kitchen, was equipped with a self-closing device. The door closed but failed to latch.

8. 7. At 9:19 a.m., the self-closing device on the door to the emergency department treatment area was disabled.

Based on observation and interview, the facility failed to maintain their vertical openings. This was evidenced by unsealed conduits penetrating the floor on the second level. This affected one of two smoke compartments on the first level and the top level maintenance rooms. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff on 5/17/12, the mechanical rooms and storage rooms on the second floor were observed.

At 9:49 a.m., there was an approximately 3 inch unsealed conduit, an approximately 2 inch unsealed conduit, and an approximately 1 inch unsealed conduit, going through the floor of the second story storage room. There was an approximately 1 inch penetration around the 1 inch conduit. Communication and telephone wires were run through the conduits.

During an interview at 9:50 a.m., Maintenance Staff 1 stated that the storage room is located above the laboratory.

Based on observation and interview, the facility failed to maintain their exits, as evidenced by exit doors that were not marked by approved signs. This affected two of two smoke compartments and could result in a delay in evacuation, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
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.

Findings:

During a facility tour with staff from 5/16/12 to 5/17/12, the exits were observed.

1. At 2:50 p.m., on 5/16/12, the exit sign near the lobby door was not visible from the North corridor of the hospital. The exit sign was facing South with an arrow pointing West, marking the lobby as an exit door.
During an interview at 2:51 p.m., Maintenance Staff 1 agreed that only the side of the exit sign was visible to the North corridor.

2. At 9:12 a.m., on 5/17/12, there was no exit sign marking the door leading from the X-ray corridor into the emergency department waiting room. There was an exit door from the emergency department waiting room leading to the outside of the building.
During an interview at 9:13 a.m., Maintenance Staff 1 confirmed that the door to the emergency department waiting room is an exit.

Based on observation, record review, and interview, the facility failed to maintain their battery-powered emergency lighting. This was evidenced by no records for testing battery-powered emergency bullfrog type lights, by no records for testing exit signs with battery-powered emergency illumination sources, and by bullfrog lights that failed to illuminate when tested. This affected two of two smoke compartments and could result in no illumination in the operating rooms and other areas in the facility, in the event of generator failure during a power outage.

NFPA 101 Life Safety Code, 2000 Edition.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. (See Chapter 2 for definition of Patient Care Area.)
5. Wiring in Anesthetizing Locations.
e. 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).

Findings:

During record review on 5/16/12, at 2:12 p.m., no records for testing the bullfrog lights and the exit signs were provided by the facility.

During the facility tour on 5/16/12 and 5/17/12, emergency battery-powered bull frog lights, and exit signs provided with battery-powered emergency lighting, were observed throughout the facility.

May 16, 2012
1. At 3:15 p.m., the bullfrog light, outside the surgery center wrapping room, failed to illuminate when tested.

2. At 3:21 p.m., the bullfrog light in Operating Room 1 failed to illuminate when tested. Operating Room 1 was the only room in the hospital used for surgery. The battery was replaced, and the unit repaired, at 4:04 p.m.

During an interview at 8:31 a.m., on 5/17/12, Maintenance Staff 1 stated that the batteries in the exit signs were tested for 5 seconds daily. He stated that the bullfrog lights and exit signs were not tested monthly for 30 seconds or annually for 90 minutes as required.

Based on observation and interview, the facility failed to ensure the means of egress were free of all obstructions, as evidenced by obstructions in one exit corridor. This affected one of two smoke compartments and could result in a delayed evacuation, in the event of a fire.

Findings:

During a facility tour with staff from 5/16/12 to 5/17/12, the exit corridors were observed.

On 5/16/12, at 9:51 a.m. and 2:45 p.m., there were seven wheelchairs stored in the North corridor near the lobby. This narrowed the corridor width to approximately 4 feet.

During an interview at 2:46 p.m., Maintenance Staff 1 stated that the wheelchairs were not used all the time and are stored near the entrance because there is limited storage space in the facility.

Based on observation, the facility failed to ensure that oxygen storage areas are maintained in accordance with NFPA 99. This was evidenced by a light switch in the medical gas storage area that was less than 5 feet from the floor, and by combustibles that were stored near medical gas cylinders. This affected the exterior oxygen storage area and could result in an increased risk of a fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Findings:

During a facility tour with staff on 5/17/12, the exterior medical gas storage and supply room was observed. The medical gas cylinders were stored in a non-sprinklered concrete room approximately 75 feet from the hospital.

At 8:44 a.m., the light switch in the medical gas room was approximately 4 feet from the floor. There were more than 90 plastic 5 gallon water bottles, stored in plastic racks, in the room, less than 2 feet away from the medical gas cylinders.

Based on record review and interview, the facility failed to ensure that the humidity in the operating room was maintained at or above 35%. This was evidenced by records showing humidity levels of less than 25% in the operating room in 2012, and by no records for humidity levels in the operating room during 2011. This affected one of two smoke compartments and could result in the increased risk of a fire.

Findings:

During record review with staff on 5/16/12, the humidity logs for the operating rooms were requested. Maintenance Staff 1 and Surgical Nurse 1 stated that Operating Room 1 is the only room used for surgery.

At 3:35 p.m., a document titled "Daily Humidity Control and Temperature Log in OR 1 for 2012" was provided. No log for 2011 humidity levels was provided. The document showed that on days where surgeries were performed in Operating Room 1, during 2012, the humidity levels were between 20 and 24%.

During an interview at 3:36 p.m., Surgical Nurse 1 stated that the humidity level in OR 1 is checked in the mornings on days when surgeries are scheduled. She stated that hospital policy is that humidity in the operating room is to be maintained between 30 and 60%.

Based on observation and interview, the facility failed to maintain their emergency generator in accordance with NFPA 99. This was evidenced by no remote alarm annunciator panel at a regularly attended work station. This affected two of two smoke compartments and could result in a delay in repairing the emergency generator.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
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:
1. When the emergency 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. Over crank (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.

Findings:

During a facility tour with staff on 5/17/12, the diesel generator was observed.

At 9:26 a.m., the generator had an alarm annunciator outside the generator room. The annunciator had an audible alarm that activates in the event the facility runs on generator power, and in the event of a battery malfunction.

During an interview at 9:27 a.m., Maintenance Staff 1 stated that the exterior generator room is approximately 75 feet from the emergency department. Staff do not continuously monitor the annunciator. He reported there was no other annunciator in a continuously monitored location.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by a surge protector plugged into another surge protector, and by one electrical box that was missing a cover. This affected one of two smoke compartments and could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.


Findings:

During the facility tour with staff on 5/16/12 and 5/17/12, the electrical wiring was observed.

May 16, 2012 -
1. At 2:52 p.m., there was a six-plug surge protector plugged into another six-plug surge protector, in the gift shop.

2. At 3:20 p.m., there was an approximately 8 inch by 6 inch electrical box with no cover, in the surgery department women's locker room. Wires were exposed and protruding out of the electrical box.

Based on observation, the facility failed to maintain their ABHR dispensers, as evidenced by ABHR dispensers that were installed over ignition sources. This affected two of two smoke compartments and could result in an increased risk of a fire.

Findings:

During a facility tour with maintenance staff on 5/16/12 and 5/17/12, the ABHR dispensers were observed.

1. At 3:11 p.m., on 5/16/12, the ABHR dispenser in the surgery department, outside the wrapping room, was installed approximately 3 feet above an electrical outlet. There was evidence of splatter on the cover of the outlet.

2. At 4:38 p.m., on 5/16/12, the ABHR dispenser in the kitchen, outside the manager's office, was installed approximately 1 foot directly above a light switch.

3. At 8:20 a.m., on 5/17/12, the ABHR dispenser in the lobby was installed approximately 3 feet directly above an electrical outlet.