HospitalInspections.org

Based on observation it was determined the facility failed to ensure 2 hour fire wall seperation from different occupancies. Findings:

On 10/15/15 at 2:01 p.m., the two hour fire wall barrier seperating the hospital from the nursing home had 8 penetrations.

The maintenance supervisor acknowledged the penetrations to the fire barrier wall located near the hospital exit to the nursing home.

At 4:46 p.m., the two hour fire wall barrier seperating the hospital from the doctor's clinic had 3 penetrations.

The maintenance supervisor acknowledged the penetrations to the fire barrier wall located near the hospital exit to the doctor's clinic.

Based on observation it was determined that the facility failed to ensure that doors were equipped with positive latching hardware. Findings:

On 10/15/15 at 1:26 p.m., it was observed the doors to the clean linen and dirty linen hazardous rooms did not have positive latching hardware as required.

At 1:27 p.m., it was observed that the door to the maintenance room did not have positive latching hardware as required.

At 2:12 p.m., it was observed the linen room by patient room 109 did not have positive latching hardware as required.

Based on observation the facility failed to ensure seperation and protection of hazardous areas. Findings:

It was observed on 10/15/15 at 1:01 p.m., the door to the mainteance room hazardous area was held open by a piece of wood placed under the door.

It was observed at 1:25 p.m., a door seperating the clean linen room and the dirty linen room was not sealed.


It was observed at 4:05 p.m., 12 E medical oxygen tanks and several aceteylene tanks stored within the same room as was housing the emergency generator.

Based on observation and staff interview it was determined the facility failed to ensure exit access was unimpeded from dead bolt locks from individual habitable spaces. Findings:

On 10/15/15 at 1:33 p.m., it was observed within the kitchen there were two doors with padlocks installed on them. There was a padlock on the door leading to the room housing the walkin freezers. A second door near the walkin freezers also had a padlock on it.

At 1:39 p.m., it was observed that the door on the corridor to the pharmacy storage area had a padlock installed. This door leads to the exit access corridor. There are only two exits out of the pharmacy area: main door and pharmcy storeage room.

At 1:40 p.m., the pharmacist was asked if there was a fire at the main door to the pharmancy which how would she gain access to the exit access corridor. She said that she would go through the pharmacy storeage door that has the padlock on it.

Based on observation it was determined the facility failed to ensure directional exit signs were properly displayed indicating the route of exit egress. Findings:

On 10/15/15 at 1:29 p.m., the illuminated exit sign by the supply room indicated the path of exit egress was to the right. The path of exit egress was to the left.

At 1:34 p.m., the illuminated exit sign at the exit near the maintenance room indicated the path of exit egress was to the right. The exit was straight. The exit sign had the chevron indicating to go right of the exit, which leads into the boiler room and/or the maintenance room.

The maintenance supervisor acknowledged the two exit signs with the chevron indicating the wrong exit path.

Based on observation it was determined the facility failed to ensure egress pathways were continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency. Findings:

On 10/15/15 at 1:17 p.m., it was observed two large wheeled trash bins were stored within the corridor near the maintenance room.

The maintenance supervisor acknowledged the two wheeled trash bins stored in the corridor.

Based on observation and interview with staff, the facility failed to ensure trash and biohazardous waste collection receptacles exceeding 32 gallons were stored in a room protected as a hazardous area when not attended. Findings:

It was observed on 10/15/15 at 1:14 p.m. it was observed two large wheeled plastic trash bins were stored within and open to the corridor located between the supply storeroom and the maintenance room doorway. The bin containing biohazard waste was 32'x44' and approximately 3.5 feet deep. The bin containing shreaded papers mixed with corrigated boxes was 41'x29' and approximately 3.5 feet deep.

At 2:29 p.m., it was observed one trash container larger than 32 gallons was located in the decontamination room. The door to the contamination room had a metal hold open device installed on it which made the room open to the corridor.

NFPA 101, 2000 Edition,
Chapter 19.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.

Based on observation it was determined the facility failed to ensure medical gas cylindars were secured. Findings:

On 10/10/15 at 4:20 p.m., a oxygen H tank was observed to be unsecured at the oxygen storeage area.

The purchasing director and maintenance supervisor acknowledged the unsecured oxygen tank.

Based on observation, record review and staff interview it was determined that the facility failed to ensure their Type I EES transfer switches were provided a routine maintenance program, periodic inspection and operational testing. Findings:

On 10/15/15 at 3:44 p.m., the facility staff were asked for the inspection and maintenance reports for their Type I EES system transfer switch. The maintenance supervisor and purchasing director stated that they did not have them. The purchasing director advised it had not been done.

NFPA 110, 2000 Edition, Chapter 1
1-1.2
Power systems covered in this standard include power sources, transfer equipment, controls, supervisory equipment, and all related electrical and mechanical auxiliary and accessory equipment needed to supply electrical power to the load terminals of the transfer equipment.
1-1.3
This standard covers installation, maintenance, operation, and testing requirements as they pertain to the performance of the emergency power supply system (EPSS).

NFPA 110. 2000 Edition,
Chapter 6 Routine Maintenance and Operational Testing
6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
6-3.2
A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-3.5*
Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.

Based on observation it was determined the facility failed to ensure the Type I EES was divided into critical branch, and life safety branch. Findings:

On 10/15/15 at 12:15 p.m., it was observed the facility had electrical panels that were not labeled as to identify it as critical branch or life safety branch. On inspection of the contents of each electrical panel it was observed each of the electrical panels appeared to have elements of the critical and life safety branches mixed together.

NFPA 99, 1999 Edition, Chapter 3 Electrical Systems
3-4.2.2 Specific Requirements.
3-4.2.2.1* General.
Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation.
Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

NFPA 99, 1999 Edition,
Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Based on observation it was determined the facility failed to ensure hydroculators were plugged directly into a GFCI receptacle. Findings:

On 10/15/15 at 2:06 p.m., two physcial therapy hydroculators were observed to be plugged into a relocatable power tap.

The maintenance supervisor acknowledged the use of a relocatable power tap with the two hydroculators.