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Based on observation and interview the facility failed to ensure egress access to corridors were continuously maintained free of all obstructions to full use in case of emergency as required in NFPA 101, 2012 Edition, Chapter 7.1.10.1 and 19.2.1.

Findings:

On 10/24/17 at 12:04 pm computer terminals, cables, plastic wheeled cart holding computer monitors and cardboard boxes were observed to be stored in the egress corridor pathway at the IT office located on the second floor. The clearance distance of the egress corridor where the computer equipment was stored was measured to be less than two feet instead of the four feet minimum requirement.

On 10/24/17 at 12:08 pm the director of plant operations was asked why the computer equipment was stored within the egress corridor. He stated he has tried to have the area cleared with no success.

Based on observation and interview the facility failed to ensure doors in a required means of egress were not equipped with a lock that required the use of a key from the egress side and egress corridor access door(s) required only one action to open as required by NFPA 101, 2012 Edition, Chapter 19.2.2.2.4.

Findings:

On 10/25/17 at 11:13 am a deadbolt lock was observed to be on patient room door 223.

On 10/25/17 at 11:13 am the surveyor asked the director of plant operations why a deadbolt keyed lock was on patient room door 223. He stated they will get the door fixed.

On 10/25/17 at 11:22 am a deadbolt lock was observed to be installed on a corridor door located in the men's labor and delivery locker room.

On 10/25/17 at 11:22 am the surveyor asked the director of plant operations why a deadbolt keyed lock was on the corridor door in the men's locker room. He stated they will get the door fixed.

On 10/25/17 at 2:39 pm two doors to the kitchen were observed to have deadbolt's installed which would not allow a person from the egress side to exit without the use of a key, and would take two actions to open the exit access corridor door.

On 10/25/17 at 2:39 pm the surveyor asked the director of plant operations why a deadbolt keyed lock was on the kitchen doors. He stated they wanted to restrict access to the food in the kitchen after hours.

Based on observation and interview, the facility failed to ensure each emergency exit discharge area was provided with emergency powered lighting as required in NFPA 101, 2012 Edition, Chapter 7.8 and 19.2.8.

Findings:

On 10/24/17 at 2:04 pm the surveyor observed each of the exit discharges of the facility to include the exit discharge area located at the main entrance, south entrance, west entrance and exit discharge area located near the cafeteria to have lighting fixtures on normal power.

On 10/24/17 at 2:04 pm the director of plant operations stated he did not know what existing light fixtures located in the facility or at each exit discharge areas were wired to and powered by the emergency generator or on emergency battery powered backed up lighting.

Based on observation and interview the facility failed to ensure hazardous area doors had self-closing hardware as required by NFPA 101, 2012 Edition Chapter 19.3.2.1.3 and were free of penetrations as required by NFPA 101, 2012 Edition, Chapter 8.7.1 and not having combustible items stored in hazardous areas as required.

Findings:

On 10/24/17 at 1:56 pm a bathroom door was observed to not have positive latching hardware located near the emergency room.

On 10/24/17 at 1:56 pm the director of plant operations was asked why the latching hardware was not working. He stated he was not aware the latching hardware was not working.

On 10/24/17 at 3:17 pm a house keeping closet near the emergency room had no self-closing hardware.

On 10/24/17 at 3:17 pm the director of plant operations was asked why there was no self-closing hardware on the door. He stated he was not aware it was missing.

On 10/25/17 at 10:16 am the materials management office was observed to have five penetrations to its fire barrier walls which would allow fire/smoke to spread into other parts of the facility.

On 10/25/17 at 10:16 am the surveyor asked the director of plant operations why the penetrations were not filled with firestop material. He stated the areas were overlooked by staff.

On 10/25/17 at 10:33 am a electrical closet located near the plant operations office was observed to have seven penetrations to its fire barrier walls which would allow the spread of fire/smoke into other parts of the facility.

On 10/25/17 at 10:33 am the surveyor asked the director of plant operations why the penetrations were not filled with firestop material. He stated they must of been overlooked by staff.

On 10/25/17 at 11:01 am a housekeeping closet labeled as 2-89 was observed to not have self-closing hardware.

On 10/25/17 at 11:01 am the surveyor asked the director of plant operations why the housekeeping closet did not have self-closing hardware installed. He stated it was missed by staff.

On 10/25/17 at 11:08 am a hazardous area mechanical room numbered 2-71 was observed to have a six foot by three foot portion of wall missing which would allow fire and smoke to spread into the plenum space within the exit corridor.

On 10/25/17 at 11:08 am the surveyor asked the director of plant operations why the portion of the wall in the hazardous area mechanical room was missing. He stated the area was overlooked by staff.

On 10/25/17 at 11:10 am a clean linen storage room located by room 2-65 was observed to have nine half inch holes in the walls which would allow fire/smoke into other parts of the facility.

On 10/25/17 at 11:10 am the surveyor asked the director of plant operations why the penetrations in the closet were not filled with firestop material. He stated staff took out shelving but failed to go back to fill the holes.

On 10/25/17 at 11:23 am a electrical closet located near labor and delivery was observed to have five penetrations which would allow fire/smoke into other parts of the facility.

On 10/25/17 at 11:23 am the surveyor asked the director of plant operations why there were penetrations not filled with firestop material in the electrical closet. He stated they were overlooked by staff.

On 10/25/17 at 11:27 am an electrical closet located across from room 204 was observed to have four penetrations and combustible material, hospital bed items, and five shelf storage shelf stored within the room.

On 10/25/17 at 11:27 am the surveyor asked the director of plant operations why there were penetrations in the electrical closet. He stated they were overlooked by staff.

Based on record review, observation, and interview the facility failed to ensure heating, cooling, and ventilation were in accordance with ASHRAE 170-2013 requirements.

Findings:

On 10/20/17 at 12:04 pm the surveyor requested test and balance annual reports for 2017, 2016, 2015, and 2014 from the director of plant operations. The director of plant operations could not provide the test and balance annual inspection reports for 2017, 2016, 2015 and 2014 as they did not exist.

On 10/24/17 at 9:50 am the surveyor asked the surgical nurse manager what procedures were performed in each of the hospital's two operating rooms. She stated they perform endoscopic procedures in operating room #2 and regular surgeries in operating room #1.

On 10/24/17 at 10:00 am operating room #2 had a room pressure monitor indicating the room was positively mechanically ventilated. ASHRAE 170-2013 requires procedure areas in which endoscopic procedures are performed are to be negatively mechanically ventilated.

On 10/24/17 at 1:56 pm, the temperature and relative humidity logs were reviewed for 2017 and 2016. The following days the relative humidity (RH) levels were above the maximum range of 60%RH:

OR#1 OR#2
10/20/17, 67.7%
10/19/17, 63.3%
10/12/17, 62.9%
10/11/17, 61.3%
10/10/17, 61.6% 62.1%
10/09/17, 61.5%
10/05/17, 62.5%
08/18/17, 94.9%

OR#1 OR#2
07/07/16, 62.1%
06/23/16, 94.0%
06/22/16, 87.3%
06/20/16, 64.0%
06/15/16, 67.6% 64.8%
06/14/16, 67.6% 61.2%

Based on record review and interview the facility failed to ensure fire alarm systems were tested and maintained with records of systems acceptance, maintenance and testing being readily available as required in NFPA 70, NFPA 72, NFPA 25 and NFPA 101, 2012 Edition Chapter 9.7.5, 9.7.7, 9.7.8.

On 10/20/17 at 12:04 pm review of fire alarm system inspection reports revealed the following:

a) Mac Systems annual sprinkler inspection dated 02/15/16 indicated two 155 degree sprinkler heads were corroded and needs replacing.

b) Mac Systems fire detection and alarm annual inspection dated 04/20/16 indicated elevator recall did not work, air handling unit #8 did not shutdown when the duct detector was tested, and the nurse call system needed service.

c) Mac Systems annual sprinkler inspection dated 02/14/17 indicated gauges on sprinkler system riser were out of date needing to be replaced, a pendant sprinkler head in front of grill in kitchen was corroded needing replacement, corrosion on two 155 degree sprinkler heads needing replaced, a 1.75 pendant sprinkler head in front of surgery was missing color designation in bulb, and the fire department connections were missing protective metal caps.

On 10/24/17 at 12:05 pm the surveyor requested documentation of the repairs indicated on the three Mac Systems inspection reports dated 02/15/16, 04/20/16 and 02/14/17 from the director of plant operations. The director of plant operations could not provide documentation which verified each item identified in the three Mac Systems inspection reports were replaced or repaired as required.

Based on record review and interview the facility failed to ensure smoke detector sensitivity testing was completed as required.

Findings:

On 10/20/17 at 10:22 am the director of plant operations was asked for smoke detector sensitivity testing inspection reports. The director of plant operations stated smoke detector sensitivity testing has not been done and no reports are available.

Based on observation and interview the facility failed to ensure doors in smoke barriers were constructed to resist fire for a minimum of 20 minutes as required in NFPA 101, 2012 Edition, Chapter 19.3.7.6 and doors to have fixed fire window assemblies in accordance with NFPA 101, 2012 Edition, Chapter 8.5.

Findings:

On 10/25/17 at 11:09 am a corridor door on the first floor leading to clean linen storage was observed to have a door with a fire rated glass panel which had gaps at the bottom of the glass over an 1/8 inch which would allow fire/smoke into the egress corridor or from the corridor into the clean linen storage area.

On 10/25/17 at 11:09 am the surveyor asked the director of plant operations why there were open gaps in the fire rated glass assembly installed on the corridor door to the clean linen storage. He stated the original fire glass had broken and they replaced the glass themselves.

Based on observation and interview the facility failed to ensure biomedical equipment in service was currently inspected as required by NFPA 70 - National Electrical Code, and NFPA 101, 2012 Edition, Chapters 9.1.1, 9.1.2, and 19.5.1.1 and electrical equipment was installed and maintained as required by NFPA 70 - National Electrical Code.

Findings:

On 10/24/17 at 1:29 pm a portable x-ray machine was observed to have an inspection label indicating it was last inspected on 01/15/15.

On 10/24/17 at 1:29 pm the radiology manager was asked if the portable x-ray machine was in-service or if it could be used. She stated it is usable but they are leasing another one that is their first line one to use. She further stated if the first line one broke they would use the second one.

On 10/24/17 at 2:45 pm an open junction box was observed in operating room #2.

On 10/24/17 at 2:45 pm the director of plant operations acknowledged the open junction box in operating room #2 and stated it would be fixed.

On 10/25/17 at 10:22 am a hydrocollator located in the physical therapy department was observed to be plugged into a non-GFCI electrical receptacle.

On 10/25/17 at 10:22 am the director of plant operations acknowledged the hydrocollator plugged into a non-GFCI electrical receptacle and stated it would be corrected.

On 10/25/17 at 10:24 am a refrigerator was observed to be plugged into a power tap in the physical therapy department.

On 10/25/17 at 10:24 am the director of plant operations acknowledged the refrigerator plugged into a power tap and stated it would be corrected.

On 10/25/17 at 10:40 am two open junction boxes were observed in the electrical room near the plant operations office.

On 10/25/17 at 10:40 am the director of plant operations acknowledged the refrigerator plugged into a power tap and stated it would be corrected.

On 10/25/17 at 11:08 am a hazardous area mechanical room numbered 2-71 was observed to have two open electrical junction boxes.

On 10/25/17 at 11:08 am the director of plant operations acknowledged the two open junction boxes in the hazardous area mechanical room 2-71 and stated it would be corrected.

On 10/25/17 at 11:10 am the nourishment room had a non-GFCI electrical receptacles within six feet of a counter top water source.

On 10/25/17 at 11:10 am the director of plant operations acknowledged the non-GFCI electrical receptacle within six feet of a counter top water source and stated it would be corrected.

On 10/25/17 at 11:27 am an electrical closet located across from room 204 was observed to have an open junction box.

On 10/25/17 at 11:27 am the director of plant operations acknowledged the open junction box across from room 204 and stated it would be corrected.

On 10/25/17 at 11:43 am the surveyor observed five clamp tubing machines and one PCA Plus II infuser located in the pharmacy with preventive maintenance inspection stickers dated 12/2014.

On 10/25/17 at 11:43 am the director of pharmacy was asked if the five clamp tubing machines and PCA Plus II infuser were or cold be used. She stated yes and they should have been inspected when the bio med person was there.

On 10/25/17 at 11:44 am three electrical receptacles located in the pharmacy were observed within six feet of a countertop water source and were not GFCI protected.

On 10/25/17 at 11:44 am the director of plant operations acknowledged the three non-GFCI electrical receptacles near the pharmacy sink and said they would be corrected.

Based on record review and interview the facility failed to ensure fire drills were conducted as required by NFPA 101, 2012 Edition, Chapters 19.7.1.4 through 19.7.1.7.

Findings:

On 10/20/17 at 11:03 am record review of facility fire drills showed there was no documentation indicating the fire drills included a verification of the transmission of a fire alarm signal as required.

On 10/20/17 at 11:03 am the director of plant operations reviewed the fire drills and stated they did not include documentation verifying the fire alarm signal transmission during each of the facility's fire drills.

Based on observation and interview the facility failed to ensure soiled linen/biohazard waste collection receptacles were stored in a protected hazardous area when not attended as required in NFPA 101, 2012 Edition, Chapter 19.7.5.7.

Findings:

On 10/24/17 at 2:22 pm three 32 gallon soiled linen/hazardous waste collection receptacles were observed to be stored in an alcove open to the egress corridor located near the exit to the west side of the facility. The requirement is a total container capacity of 32 gallons shall not be exceeded within any 64 square feet area and should be located in a room protected as a hazardous area when not attended. The containers for combustibles were not labeled and not listed as meeting FM Approval Standard 6921 or equivalent as required.

On 10/24/17 at 2:23 pm the director of plant operations acknowledged the three 32 gallon containers stored in an alcove open to the corridor.

Based on record review and interview the facility failed to ensure the nonexempted operating room engineered smoke control systems were tested in accordance with established engineering principles as required in NFPA 101, 2012 Edition, Chapter 19.7.7.

Findings:

On 10/24/17 at 12:32 pm the surveyor reviewed the fire alarm vendors annual inspection report for 2017, 2016, 2015 and 2014 each one did not include the smoke evacuation system in the operating room.

On 10/24/17 at 01:00 pm the surveyor asked the director of plant operations for the annual operating rooms smoke evacuation system testing for 2017, 2016, 2015 and 2014. The director of plant operations could not provide the annual operating rooms smoke evacuation system testing inspections. He stated the testing has not been done and no inspections are available.

Based on interview the facility failed to ensure completing building systems risk assessments for the medical gas system as required by NFPA 99, 2012 Edition, Chapters 5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5.

Findings:

On 10/20/17 at 11:00 am the director of plant operations was asked for the building systems risk assessment for the medical gas system. The director of plant operations could not provide the building systems risk assessment for their medical gas system because the assessments don't exist.

Based on record review and interview the facility failed to ensure the medical gas systems were maintained and inspected on an annual basis as required in NFPA 99, 2012 Edition, Chapters 5.1.14.4, 5.1.14.4.4, 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13.4 and the facility failed to ensure an annual review of bulk system capacity to ensure the source system has sufficient capacity as required in NFPA 99, 2012 Edition, Chapter 5.1.14.4.3.

Findings:

On 10/20/17 at 10:22 am the surveyor requested the facility's medical gas system annual certification inspections and inspection report for the review of bulk system capacity for 2017, 2016, 2015, and 2014 from the director of plant operations. The director of plant operations provided three documents which on review indicated three different years in which repair and upgrade work was done on their medical gas system. The three documents were not annual medical gas certification inspections.

On 10/20/17 at 10:22 am the surveyor asked the director of plant operations where the full and complete annual medical gas system inspections were and he stated if it is not in the three documents he gave me they don't have it. The director of plant operations could not provide the medical gas system annual certifcation inspections and annual inspections for the review of bulk system capacity for 2017, 2016, 2015, and 2014 as they do not exist.

Based on interview the facility failed to ensure the Type 1 Essential Electrical System (EES) was divided into three branch panels the life safety branch, critical branch and the equipment branch as required by NFPA 99, 2012 Edition, Chapter 6.4.2.2.1.1.

Findings:

On 10/25/17 at 2:37 pm the director of plant operations was asked where the three required branch panels (life safety, critical and other equipment) were located. The director of plant operations stated the facility generator has only one branch panel.

Based on interview the facility failed to ensure the facility's building system risk assessments for their essential electric system (EES) as required by NFPA 99, 2012 Edition, Chapters 3.3.138, 6.3.2.2.10, 6.6.2.2.2, and TIA 12-3.

Findings:

On 10/20/17 at 1:17 pm the director of plant operations was asked for the building systems risk assessment for their essential electrical systems. The director of plant operations could not provide the building systems EES risk assessment because the assessments don't exist.