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Based on record review and interview with staff, the facility failed to inspect and maintain the Fire Suppression System in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings include:

The First Check needs to be replaced in accordance with the Annual Inspection conducted 10-17-2012 by Simplex/Grinnell. The Governing Body failed to require the facility to read, sign, and act upon the the report's deficiencies.

Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air-conditioning that complies with the provisions of Section 9.2 and installed in accordance with the manufacturer's specifications. The Governing Body also failed to review the provisions of Section 9.2. Refer to NFPA 101, 2000 Edition, Section 5.1.7, 9.2, 19.5.2.1, 19.5.2.2, NFPA 90A.

Findings include:

The Clean Work Room originally designed to accept and prepare equipment and instruments for the sterilization process was being used as an Endoscope Procedure Room. Section 5.1.7, Maintenance of Design Features, reads "the design features required for the building to continue to meet the performance goals and objectives of this Code and shall be maintained for the life of the building. Such performance goals and objectives shall include complying with all documented assumptions and design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change. " The Clean Work Room was not submitted for review for use as an Endoscope Procedure Room and does not meet the requirements of hospital standards.

The ventilation requirements in an Endoscope Room is negative. The clean work room was originally designed as positive air flow. The facility did not revise the mechanical design of the room to meet requirements. The Soiled work room was compromised as there is no longer a flow of dirty area to clean area for instrument sterilization, and the negative requirements for the soiled now included parts of the clean area. Refer to Chapter 667, Appendix A, Ventilation Requirements For Areas Affecting Patient Care In Hospitals and Outpatient Facilities.

Based on observation and interview with staff, the Governing Body failed to review and the facility failed to provide heating, ventilating, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. NFPA 101 2000 edition chapter 5-1.7 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

The Emergency back up fuel tanks(Four - 500 gallon propane tanks) for heating were empty and were not being monitored. The facility had never opened the gate that housed the tanks. At the time of the survey the CEO cut the lock off and ordered fuel.

The boiler was out of service and had no work order for repair.

Based on observation and interview with staff, the Governing Body responsible for the structure that has the elements of hospital operation for Building Design, Purchasing, inspection,maintenance schedules,and training programs failed to oversee implementation of said responsibilities. NFPA 99, 1999 Edition, Chapter 12-2.1.

Findings include:

1 The facility has failed to implement a Preventive Maintenance Program that covers all equipment and building services. A preventive maintenance program shall be established and approved by the governing body.

2 Bio-Medical Equipment program is not implemented. The equipment was not checked completely, and staff was not trained to remove equipment that is out of date from service. A Bio-Medical program shall be established and approved by the governing body .

3 The facility failed to inspect, document, and the governing body failed to require and review testing of the Electrical Equipment and Wiring in accordance with NFPA 99, 1999 Edition, Chapter 3-3.3.2.1 through 3-3.4.3.1. Receptacles/ Patient Electrical Outlets in Patient Care Areas were not maintained and tested. The outlets shall be tested for Impedance Measurements, Physical Integrity, Continuity, Correct Polarity, and Retention Force.

Based on observation and record review, the facility failed to inspect generators weekly and exercise under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1.
Findings include:

There was no documentation that the generator was being exercised under load for 30 minutes per month. Staff explained that the former staff member explained that the facility was not required to run under load because the generator ran automatically every week.