HospitalInspections.org

Based on direct conversation with facility management the facility does not maintain the required laboratory (Lab) emergency procedures. Failure to develop and maintain emergency procedures for labs could result in injury or death to staff of patients
NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.3.2.2 * Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 9 Heating, Ventilation, and Air Conditioning (HVAC). 9.3.1.2 Laboratories shall comply with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals.
NFPA 45 Standard on Fire Protection for Laboratories Using Chemicals 2011 editionChapter 6. section 6.6.3 Emergency Plans.6.6.3.1 Plan for Laboratory emergencies shall be developed which shall include the following:1. Alarm activation2. Evacuation and building reentry3. Shutdown procedures or applicable emergency operations for equipment, processes. Ventilation devices, and enclosures.4 Firefighting operations5. Non-fire Hazards6.6.3.2 Procedures for extinguishing clothing fires shall be established.
Findings include:
Observations while on tour October 21-22, 2024, revealed the laboratory (Lab) did not create an emergency procedure covering the requirements of NFPA 45. Staff and management were questioned and only referred to the chemical SDS ' s for emergencies.

Employees # 1 and # 2 confirmed the missing emergency procedures during the exit conference on October 22, 2024.

Based on observation it was determined the facility failed to fill penetrations in two (2) of the smoke barriers in the facility. Failing seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

During a facility tour conducted on October 21-22, 2024, revealed the facility failed to maintain the in the fire/ smoke barrier around the pharmacy. a Active shooter pass through glass partion was installed in the firewall which has built in holes for speaking and passing of medications.

During the exit conference conducted on October 21-22, 2024, employees #1 and #2 confirmed by visual inspection the bullet proof glass in the Pharmacy pass through has hole built into the partion.

Based on Observation, it was determined that the facility allowed the use of power strips but did not use the wall outlet receptacles for appliances. Failure to properly use power strips and outlets could lead to electrical overload or fire, which could harm the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2, "All Patient Care Areas," Sections 6.3.2. 2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

Observations made during the tour from October 21-22, 2024, revealed that the following locations had power strips plugged into extension cords (daisy chained) and not mounted in the operating rooms. The first operating rooms had a non-UL1363A or UL60601 rated power strip and in one was plugged into an extension cord. Additionally, there was a non-ul rated residential type extension cord being used to power a sound system.

During the exit conference conducted on October 21-22, 2024, Employees # 1 and #2 confirmed the improper use of power strips and extension cords in the operating rooms.

Based on Observation the facility failed to properly store full oxygen (O2) cylinders. This could result in the combustible items becoming oxygen-saturated and easily ignitable which could cause a fire to start prematurely. Failing to properly store oxygen could result in personnel entering the area unaware of the hazards inside
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.5. Special Precautions - Storage of Cylinders and Containers. Section 11.6.5.4 #3 During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.
NFPA Chapter 5 section 5.1.3.3.1.7
Cylinders in use and in storage shall be prevented from reaching temperatures in excess of 54°C (130°F).
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.4.1 'A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING"
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.2.3 "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft)(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3)Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour
Findings include:
Observation while on a tour conducted on October 21-22, 2024, revealed the following locations with Oxygen being stored properly in areas without doors, non-combustible construction and not labeled correctly in the following areas.
1. Emergency room
2. Med Surge hallway
3. Operating room hallways
Additionally, one E type cylinder was freestanding not secured in trauma room # 5 in the emergency room
Oxygen storage on the helicopter pad reveals bot E and H type cylinders in open caged storage containers. These are exposed to direct sunlight, and do not have proper lambing for full or empty. The facility was not able to prove the direct sunlight temperature would not reach 130°.

Employees #1 and #2 confirmed throughout the entire tour that there is improper storage of oxygen throughout the facility.