HospitalInspections.org

Based upon observations and staff interviews on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. The facility failed to maintain its fire walls. The facility has a penetration in the kitchen west wall.
2. Electrical room in TRC building has five holes around conduit going through fire wall.
3. Fire wall above tiles in corridor by C2-258 had fire caulk that had fallen out of conduit.



The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

1. The facility failed to maintain fire door function. The facility has racks blocking the fire door to Kitchen room 139.

2. The Fire door TP room 17-1 is not not latching.

3. Stairwell three attic access door not latching building 18.

4. Stairwell 17-1 second floor fire door not latching.

5. Records room G17-10 fire door wedged open with dust pan.

6. Fire door G 17-34 not latching.

7. Fire doors between building 9 and 17 not latching.

8. The facility failed to maintain its smoke barriers. The facility has four penetrations in the cross corridor smoke doors adjacent to the chapel in building 29. (MM3 states the holes are about 3/8".)

9. Cross-corridor door outside E1 building 29 failed to close and latch.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result in tripping and fall injuries to residents, staff and/or visitors.

The findings include, but are not limited to:
Building 28 was missing the January and April emergency light testing reports.
The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility failed to maintain its kitchen hood suppression system in ward S7. The facility has a sprinkler head that has been disconnected from the sprinkler system and is still in position.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead to people within the building not being notified of a fire.

The findings include, but are not limited to:
1. The facility failed to maintain the fire alarm panel in building 21. The fire alarm panel was in trouble mode when inspected. MM4 states in process of getting repaired.
2. Main Fire Alarm panel off of the main lobby for building 17-19 was in trouble. There was a common trouble, system trouble, and a hardware supervision. The Fire Alarm Maintenance Tech 1 stated that there was no way to fix the panel as it was old and the parts were no longer in service. The mother board was not talking to the sounder card. The facility provided a letter from their Fire Alarm Tech that stated that the smoke detectors and pull stations still functioned when the panel was in trouble.
3. Building #18-19, the strobe in room 012 floor G is inoperable.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
C1-116 outside overhang off of the staff lounge was over 4ft wide, was wood, and did not have sprinkler coverage.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff, and/or visitors within the facility.
The findings include, but are not limited to:
1. The facility failed to maintain is sprinkler system. The facility has a missing escutcheon ring in building 29's 2nd floor equipment storage room.
2. Facility failed to provide required inspections for water storage tanks in accordance with NFPA 25 2011. Interior of tank shall be inspected every 5 years if the tank has corrosion protection and 3 years without.
3. Facility shall provide documentation of semi-annual exterior tank inspections. The facility states that they contacted a vendor on 05/15/2018 to obtain bids for tank inspections.
4. In the corridor by C3-340 there is a dirty sprinkler head.
5. C3-multi-purpose room had a sprinkler head falling down by the TV.
6. C5-244 closet had a bucket on a shelf directly under a sprinkler head. The bucket was within a few inches of the bottom on the sprinkler head.
7. C-225 room had a sprinkler head near the rear door that was askew.
8. C2-204 in corridor by fire rated window had a sprinkler head that was falling down.
9. C1-129 2 of 3 sprinkler heads in room were falling down.
10. Building #17 has had no main drain test due to no way to drain the water.
11. Building #17, there is no signage on the door to the sectional control valve.
12. Building #17, the main flow switch in the sprinkler room did not send a signal to the panel.
13. In building #20 there are 37 recalled heads still in operation.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:
Fire extinguisher blocked by cart in kitchen C1-102. Fixed at the time of inspection.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 54 and NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm.
The findings include, but are not limited to:
1. The facility failed to maintain its electrical outlets. There is a missing outlet cover in the sprinkler riser room of building 21.
2. The facility failed to maintain its electrical wiring. The facility has exposed wiring above the West side Kitchen entrance.
3. The facility failed to maintain its electrical wiring. The facility has exposed wiring on the switch above the door of room 105 in the Kitchen.
4. Facility failed to provide an electrical cover in building 29 floor 1 Pharmacy on wall.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.
The findings include, but are not limited to:
1. Multiple drills reported that the census was not started or taken.
2. Multiple drills stated that the fire marshal was not present. For example E1 2/7/18 at 2100; the fire alarm was not pulled and the radio was not taken with staff. On S8 2/12/2018 at 1327 the census was not taken, the radio was not taken by staff and the fire marshal and RN3 were not present.
3. The 9/17/17 fire drill started at 1236 and ended at 1336
4. The F5 fire drill on 9/13/17 was pre-announced
5. The F3 fire drill was pre-announced over the PA system before the drill started.
6. C-5 swing shift drill check list is incomplete.
7. S-9 day shift census taker did not take radio.
8. There is no drill report for the fire drill on F-7 second quarter drill on 5/10/2018.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain a written policy or regulation for residents and staff. Additionally, the facility has failed to provide the required equipment at the designated smoking area(s). This could result in the ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

1. Doctor office in C3 had a cigarette roller and tobacco. The Doctor stated that he rolls cigarettes for patients. Smoking policy 4.05 dated 8/17 section E2 prohibits staff from keeping smoking materials for patients.
2. In the C ward courtyard one of the smoking boxes was locked with a stick in the holes where the padlock would normally go. The facility is required to lock all smoking boxes with a key lock.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

1. The facility failed to maintain its generator room's two hour rating. The facility has penetrations in penthouse C leading into the generator room of building 29.

2. The facility failed to maintain its generator room's two hour rating. The facility has penetrations in penthouse D leading into the generator room of building 29.

3. Review of the facility records and interview with the facilities director indicates that Emergency generator #2 does not transfer in the required 10 seconds, it is taking 45-60 seconds.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 14-16, 2018 between approximately 0800 to 1600 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 70.



The findings include, but are not limited to:

1. The facility failed to have cord strain protection. Office room 206 in building 29 has a cord that has no strain protection plugged in. (Corrected at time of inspection)

2. Facility failed to maintain electrical cord in room building 29 room 103.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk.

The findings include, but are not limited to:

1. The facility failed to plug a power strip directly into an outlet. The facility has a power strip plugged into another power strip in the attic of building 21.

2. The facility failed to plug a power strip directly into an outlet. The facility has a power strip plugged into another power strip in the Kitchen's dry storage.

3. The facility failed to plug a power strip directly into an outlet. The facility has a power trip plugged into another power strip in A206 office of Building 29.

4. Extension cord and use C 9-306.

5. Microwave to power strip C 9- 306.

6. Coffee maker and microwave into power strip C 918 308.

7. Non approved power strip second-floor building 17 room C 8-259.

8. Room G 17-32 two extension cord in use. Fixed at time of inspection.

9. Not approved power strip in pharmacy G9-11. Fixed at time of inspection.

10. Extension cord in use office four F170.

11. Power strips daisy-chained in CFS control room.

12. Unapproved power strip in CFS office B.

13. Nurses station and approve power strip nurses station F7.



The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:


1. Facility failed to maintain exterior electrical cord sheath in Microbiology room 131. Inner electrical cord wires were found exposed during inspection.

2. The facility could not produce a policy on patient centered electrical equipment. The facility is conducting testing, however there is no policy on testing intervals and continuous education for those servicing, maintaining, and testing the equipment.



The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to maintain construction of oxygen storage areas as being smoke and fire resistant. This could result in the products of combustion traveling from the hazardous area into the exit corridor in the event of a fire which could endanger patients, first-responders, staff, and/or visitors. In addition the facility has failed to maintain exterior storage locations as secured to prevent unauthorized access. This could allow for the tampering with or damage to of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

The findings include, but are not limited to:

The facility failed to secure its oxygen cylinders. The facility has three unsecured oxygen cylinders in room 258 of ward E8. (Corrected at time of inspection)


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 5/14 to 5/16/2018 between approximately 0800 to 1600 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include, but are not limited to:

The oxygen policy for the facility did not address ongoing training.


The above was discussed and acknowledged by the facility staff.