HospitalInspections.org

Based on observation it was determined the facility failed to ensure fire barriers were protected.

Findings:

On 9/07/2016 at 12:03 p.m., 5 penetrations were observed in the fire wall barrier located at the magnetic lock door to the new wing.

The maintenance director acknowledged the penetrations to the fire wall barrier.


NFPA 101, 2000 Edition,
Chapter 19 Existing Health Care Occupancies
19.3 Protection
19.3.7 Subdivision of Building Spaces
19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
19.3.7.4
Not less than 30 net ft2 (2.8 net m2) per patient in a hospital or nursing home, or not less than 15 net ft2 (1.4 net m2) per resident in a limited care facility, shall be provided within the aggregate area of corridors, patient rooms, treatment rooms, lounge or dining areas, and other low hazard areas on each side of the smoke barrier. On stories not housing bed or litter borne patients, not less than 6 net ft2 (0.56 net m2) per occupant shall be provided on each side of the smoke barrier for the total number of occupants in adjoining compartments
19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.

Based on observation it was determined the facility failed to ensure hazardous areas within the facility were protected.
Findings:
On 09/08/16 at 11:47 a.m., while on tour of the boiler room a combustible plastic tub of x-ray acetates and a wooden cabinet was observed to be stored within the boiler room.

At 12:42 p.m., in the new wing of the facility an eletrical closet did not have a self-closer on the door.

At 12:52 p.m., a house keeping closet on the new wing was observed to have no self-closer. The clean linen room between the janitor's closet and physical therapy treatment room had no self-closer.

At 12:54 p.m., the door to of an ante-room containing coffee and water was observed to not have a self-closer.

At 13:17, the business office storage had over 15 banker boxes of medical records stored and the door did not have a self-closer, and a non- fire rate window assembly.

Based on observation it was determined the facililty failed to ensure protection of hazardous area storage.

Findings:

On 9/07/2016, the gift shop storage room was observed to not be sprinklered and not have 1 hour fire barrier seperation. There were multiple combustible materials and gift items stored.


NFPA 101, 2000 Edition
Chapter 19, Existing Health Care Occupancies
19.3.2.5
Gift shops shall be protected as hazardous areas when used for storage or display of combustibles in quantities considered hazardous. Non-rated walls may separate gift shops that are not considered hazardous, have separate protected storage and that are completely sprinkled. Gift shops may be open to the corridor if they are not considered hazardous, have separate protected storage, are completely sprinklered and do not exceed 500 square feet.

Based on observation, it was determined the facility failed to ensure keyed locks, dead bolt locks and multi latching devices did not impede egress from habitable spaces.

Findings:

On 9/07/2016, at 12:02 p.m., a roller latch was observed on an outside exit door, and 2 roller latches observed in the faciilty office.


NFPA 101, 2000 Edition
Chapter 7 Means of Egress
7.2 Means of Egress Components
7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.1

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Based on observation it was determined the facility failed to ensure emergency lighting is so arranged that failure of any single lighting fixture will not leave the area in darkness.

Findings:

On 09/08/16, after touring throughout the facility it was observed there were no existing secondary lighting arrangements to ensure that the failure of any single lighting fixture would not leave the facilitys' means of egress, including exit discharge in darkness.

Based on observation and staff interview it was determined that emergency generator powered lighting could not be confirmed throughout the facility.

Findings:

On 09/08/2016 at 10:52 a.m., during a tour of the facility emergency lighting in the facility corridors, exit accesses and exit discharge could not be identified or observed. The exit discharge near the laboratory did not have emergency egress lighting to a public way.

The maintenance director accompanying the LSC surveyors on tour was interviewed. He was asked what lights in the facility are powered by the generator. He said he knows some of the lights are on generator power but can not identify them.

At 11:43, the monthly and annual logs for inspection of battery powered emergency lighting was requested and not provided.


Emergency illumination of at least 11/2 hour duration is provided in accordance with section NFPA 101, 2000 Edition 7.9. 20.2.9.1, 21.2.9.1.

Based on observation it was determined the facility failed to ensure required automatic sprinkler system(s) were inspected, tested and maintained periodically.

Findings:

On 9/07/2016 at 10:34 a.m., on the review of facility documentation provided could not confirm that quarterly, 5-year and semi annual inspections were completed.


Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation it was determined the faclity failed to ensure trash receptacles over 32 gallons were protected.

Findings:

On 09/08/16 at 11:21 a.m., a trash container over 32 gallons was stored in the corridor outside of the gift shop storage room.

The maintenance supervisor acknowledged the gift shop storage area and trash container.

NFPA 101, 2000 Edition
Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5

Based on observation it was determined the facility failed to ensure protection of their medical gas system(s).

Findings:

On 9/07/2016 at 12:15 p.m., on tour of the facility's medical gas bank tanks, the tanks were observed to not be secured.

The maintenance director acknowledged the unsecured medical gas tanks.


NFPA 99, 1999 Edition
Chapter 4 Gas and Vacuum Systems
4-3 Level 1 Piped Systems
4-3.5.2.2 Storage of Cylinders and Containers - Level 1.
(a) * Facility authorities, in consultation with medical staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in anesthetizing locations. Storage locations for flammable inhalation anesthetic agents, established in any operating or delivery suite, shall be limited by space allocation and regulation to not more than a 48-hour normal requirement for any such suite. In storage locations, cylinders shall be properly secured in racks or adequately fastened. No cylinders containing oxygen or nitrous oxide, other than those connected to anesthetic apparatus, shall be kept or stored in anesthetizing locations.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
3. Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.

Based on record review it was determined the facility failed to ensure their generator was maintained and inspected.

Findings:

On 9/08/2016, on the review of the facility generator documentation provided could not confirm the emergency generator was excercised under load for 30 minutes per month

Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 and NFPA 110.
3-4.4.1 and 8-4.2 (NFPA 99), Chapter 6 (NFPA 110)

Based on observation it was determined the facility failed to ensure protection from eletrical wiring.

Findings:

On 09/07/2016 at 11:32 a.m., while on tour of the facility laboratory a multi-plug was oberved to be in use.

At 11:34 a.m., a refrigerator in the laboratory was last inspected on 5/08/2015.

The maintenance supervisor acknowledged the multi-plug and refrigerator plugged into a power tap.

At 13:08, on tour of the chart room an APC power supply/surge protector wa observed to be daisy chained into another surge protector.

At 13:20, a refrigerator was observed to be plugged into a power tap in the business office.