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Based on observation and staff interview it was determined the facility failed to ensure their facility separated inpatient from outpatient care areas with the required 2 hour fire resistance rated construction.

Findings:

On 11/30/16 at 12:08 p.m., an endoscopic procedure room was observed to be located in a doctor's outpatient clinic area within the health care occupancy and did not have 2 hour fire wall separation.

The facility manager acknowledged there was no 2 hour fire wall barrier serparation around the endoscopic procedure room, post operative room located in the outpatient clinic area of the facility.

The facility manager acknowledged there was no 2 hour fire wall barrier seperating the health occupancy from the business occupancy outpatient clinic.

Based on observation and staff interview it was determined the facility failed to ensure a required means of egress was not equipped with a latch or lock that requires more than one action to open from the egress side.

Findings:

On 11/30/16 at 11:30 a.m., a barrel latch was observed to be in use on the restroom door in the radiology department.

The CNO acknowledged the barrel latch in use.

On 12/01/16 at 13:51, two padlocks were observed to be installed on a patient room door where inmates were taken for care.

On 12/02/16 at 12:35 p.m., two padlocks were observed to be in use on the door to operating room #2.

The facility manager acknowledged the padlocks on the doors.

Based on observation and staff interview it was determined the facility failed to ensure hazardous area(s)/corridor doors had self closing and positive latching hardware.

Findings:

On 12/01/16 at 11:07 a.m., the doctor's lounge door on the egress corridor was observed to have no positive latching hardware.

The dirty utility room located in the surgical suite was observed to have no self-closing hardware.

The facility manager acknowleged the missing self-closing and positive latching hardware.

Based on observation and staff interview it was determined the facility failed to ensure emergency lighting of at least 1.5 hour duration was provided automatically in accordance with NFPA 101, 2012 Edition Chapter 7.9, and 19.2.9.1.

Findings:

On 12/01/16 at 13:48, exit discharge lighting could not be observed or confirmed at the exit across from patient room 203.

While on tour of the facility emergency powered lighting at each facility exit discharge could not be observed or confirmed.

The facility manager acknowledged the missing exit discharge lighting for the facility.

Based on observation and staff interview it was determined the facility failed to ensure their mechanical room was monitored to ensure it did not have combustibles stored, and to be clean/orderly.

Findings:

On 12/02/16 at 12:27 p.m., while on tour of the basement the mechanical room called "Lawson room" was observed to have combustible items stored in the hazardous area. Wooden pallets, Christmas decorations, corrugated boxes, gurneys with mattresses, and a wooden podium were observed to be stored in this hazardous area.

The facility manager acknowledged the combustible items stored in the hazardous area mechanical room.

Based on observation, record review and staff interview it was determined the facility failed to ensure rooms were properly mechanically ventilated in accordance with ASHRAE 170.

Findings:

On 12/02/16, while on tour it was observed the biohazard closet next to room #207 was not negatively ventilated. On review of the test and balance inspection report, this room was not included in the inspection testing.

The facility manager acknowledged the room not negatively ventilated.

The clean storage room located in the surgical suite could not be confirmed to be positively ventilated. On review of the test and balance inspection report, this room was not included.

Sterile bubble packed items were observed to be stored on a metal shelf in the surgical suite corridor and the surgery suite corridor could not be determined to be positively ventilated. On review of the test and balance inspection report, this area was not included in the inspection testing.

The facility manager acknowledged the area was not positively vented.

Based on observation and staff interview it was determined the facility failed to ensure alcohol based hand rub dispensers (ABHR) were properly installed.

Findings:

On 11/30/16 at 10:26a.m., a ABHR was observed to be installed over an ignition source in room 201.

The facilities manager acknowledged the ABHR installed over an ignition source.

Based on observation and staff interview it was determined the facility failed to ensure smoke detection devices were installed properly.

Findings:

On 12/02/16 at 11:00 a.m., a smoke detector was observed installed within 3 feet of a HVAC diffuser.

The facility manager acknowledged the smoke detector too close to a HVAC supply/return diffuser.

Based on observation and staff interview it was determined the facility failed to ensure their sprinkler system was installed in accordance with NFPA 13, 2010 Edition.

Findings:

On 12/01/16 at 13:01, a total of five standard response spinkler heads were observed to be installed near the main entrance, and near the administrative offices of the facility. The remainder of the sprinkler heads in both areas were observed to be quick response sprinkler heads.

The facility manager acknowledged the few standard response sprinkler heads in the same smoke compartment area with the quick response sprinkler heads.

Based on observation and staff interview it was determined the facility failed to ensure eletrical systems were in complaince with NEC 70.

Findings:

On 11/30/16 at 12:14 p.m., in the endoscopic procedure recovery/spinal injection room located in the outpatient/business occupancy area a red plug electrical receptacle located on the countertop service within 6 feet of a water source was observed to not be a GFCI receptacle.

The facility manager acknowledged the non-GFCI plug.

At 13:51, a three receptacle plug extension cord was observed to be in use in the pharmacy.

The CNO acknowleged the extension cord in use in the pharmacy.

On 12/01/16 at 10:55 a.m., a refrigerator in the doctor's lounge was observed to be plugged in a power tap.

The facility manager acknowledged the refrigerator plugged into a power tap.

At 11:01 a.m., while on tour of the facility two power taps were observed to be daisy chained in the telephone closet at the nurses station.

The CNO acknowledged the dasiy chained power taps.

Based on record review it was determined the facility failed to ensure fire drills were held quarterly and on each staff shift.

Findings:

On 12/02/16 at 13:45, on review of the facility fire drill documentation revealed fire drills for 2015- 2nd and 4th quarter second shift and 2016- 1st and 3rd quarter second shift fire drills were not completed.

Based on observation and staff interview it was determined the facility failed to ensure protection from space heaters where heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).

Findings:

On 12/02/16 at 13:45, a space heater was observed to be in use in an office housed by one facility staff member. The office was located in the closed section of the hospital. The facility staff were asked for manufactures documentation indicating the heating elemernt did not exceed 212 degrees Fahrenheit (100 Degrees Celsius). The documentation was not provided.

The facility manager acknowledged the space heater in use.

Based on staff interview it was determined the facility failed to ensure risk assessments for their building systems were conducted and completed in accordance with NFPA 99, Chapter 4.

Findings:

On 11/30/16 at 10:35 a.m., the surveyor asked the CNO for their building systems risk assessments. The CNO said the surveyor would have to ask facility management regarding those.

On 12/01/16, the facility manager was asked to provide the risk assessments for the building systems and were not provided.
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Based on observation and staff interview it was determined the facility failed to ensure the facility Type 1 EES system was divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99, 2012 Edition, 6.4.2.2.1.1.

Findings:

On 12/01/16 on inspection of the facility's Type 1 EES it was observed there was only one emergency panel.

The facility building maintance person was asked where the life safety, critical and equipment eletrical branch panels are. He said there is only one emergency electrical branch panel which the generator feeds into.
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Based on observation, record review and staff interview it was determined the facility failed to ensure and determine if the facility's generator provided a continuous load on the switch of 150kVa (120kW) or less to meet code compliance for the use of one transfer switch in accordance with NFPA 99, 2012 Edition, 6.4.2.2.1.4, (A), (B).

Findings:

On 12/02/16, while on tour of the facility only one transfer switch was observed to be installed with the Type 1 EES generator. On review of the generator logs, and generator information revealed no reports indicating the emergency generator provided a continuous load at or less than 150kVa on the switch.

The building maintenance person was asked if there were any other transfer switches on their systems. He said no we only have one transfer switch.

Based on observation and staff interview it was determined the facility failed to ensure their medical gas storage had precautionary signage in accordance with NFPA, 2012 Edition, Chapter 5.

Findings:

On 12/05/16 at 13:26, the medical gas storage building near the ER entrance was observed to have no precautionary signage on the door or anywhere on the building or area.

The facility manager acknowledged there was no signage on the medical gas storage building.

Based on observation and staff interview it was determined the facility failed to ensure patient care eletrical devices were currently inspected and tested.

Findings:

On 11/30/16 at 10:33 a.m., a CPAP machine in the sleep study patient room 203 was observed to not have a current inspection label.

The ER manager acknowledged the medical device did not have a current inspection label.

At 14:12, a portable negative pressure ventilation machine in ER room #2 was observed to not have a current inspection label.

The refrigerator in the pharmacy was observed to not have a current inspection label.

The Berchtold chromophare C-571 located in operating room #2 was observed to not have a current inspection label.

The blood bank refrigerator located in the facility laboratory was observed to not have a current inspection label.

The Phillips machine PV0280 had an inspection label indicating it was last inspected in 2014.

The CNO acknowledged the devices without a current inspection labels.

Based on observation and staff interview it was determined the facility failed to ensure their medical gas cylinders were properly stored and protected in accordance with NFPA 99, 2012 Edition.

Findings:

On 11/30/16 at 10:28 a.m., an "E" sized oxygen cylinder was observed not secured in the patient waiting area near the physical therapy department.

The CNO acknowledged the non-secured oxygen tank.

On 12/02/2016, the medical gas storage building near the emergency room entrance was observed to have one "E" sized oxygen cylinder which was non-secured.

The facility manager acknowledged the non-secured O2 "E" cylinder stored in the medical gas storage building.