HospitalInspections.org

Based on observation the facility failed to provide an adequate smoke barrier.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, the Chief Nursing Officer, the Technician, and the PCSM during the hours of the inspection from 2:00 pm to 3:30 pm on 1/12/2015 that there was a penetration in a smoke barrier in corridor at the Lab Restroom.

Based on observation the facility failed to provide an adequate hazardous area separation.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, and the Chief Nursing Officer during the hours of the inspection from 2:00 pm to 3:30 pm on 1/12/2015 that the Catering and Soda Storage in the Kitchen did not have a closer on the door.

Second Alarm for the Generator
" A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 1999: 3-4.1.1.15.

Based on observation the facility failed to provide an adequate alarm for the emergency generator.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, the Chief Nursing Officer, the Technician, and the PCSM during the hours of the inspection from 9:45 am to 1:00 pm on 1/12/2015 that there was not a generator alarm in an area where the operating personnel could observe the alarm.


Electrical Room Used for Storage

" Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded. " - NFPA 70, 2002, 110.26(B)

" Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage. " - NFPA 70, 2002, 110.26(F)


Isolation Room Pressure Relationships for Infection Control

The pressure relationships between spaces are essential for odor and infection control. NFPA 101 references all NFPA publications. Chapter 6 of NFPA 90A, 1999 references ASHRAE documents as a mandatory part of the requirements of the standard. Current ventilation tables are given by ANSI/ASHRAE/ASHE Standard 170. In addition, State Licensing Regulations control pressure relationships. Infection isolation rooms that shall be negatively pressurized relative to adjacent spaces.

Based on observation the facility failed to provide an acceptable differential pressure relationship for an isolation room.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, the Chief Nursing Officer, the Technician, and the PCSM during the hours of the inspection from 9:45 am to 1:00 pm on 1/12/2015 that the ICU, I107, was not negatively pressurized.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, the Chief Nursing Officer, the Technician, and the PCSM during the hours of the inspection from 9:45 am to 1:00 pm on 1/12/2015 that the grounding continuity was not being recorded.

Aspen: The Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. (This may not be required in existing buildings, built before March 11, 2003 if no life support equipment)

Based on observation the facility failed to provide adequate essential electrical system, EES.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, and the Chief Nursing Officer during the hours of the inspection from 2:00 pm to 3:30 pm on 1/12/2015 that there were the following issues.
1) All critical electrical receptacles in critical areas, the E.D. and crash carts locations at the ICU and Patient room 11, must be permanently labeled with the panel/breaker number supplying power to the receptacle.
2) Panel CLA did not have a directory.
3) The FACP was not cross referenced to the panel and breaker supplying power.
4) The required exits at the end of the corridors did not have a light fixture with two lamps.

Based on observation the facility failed to provide adequate signage on electrical panels.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, the Chief Nursing Officer, the Technician, and the PCSM during the hours of the inspection from 9:45 am to 1:00 pm on 1/12/2015 that there was the following issue. The electrical Panels were not labeled with the voltage, current rating and the number of phases.

Based on observation the facility failed to provide acceptable locations for alcohol based hand rub dispensers.

The inspector observed, while accompanied by the Plant Operation Manager, the Director of Quality Management, the Chief Nursing Officer, the Technician, and the PCSM during the hours of the inspection from 9:45 am to 1:00 pm on 1/12/2015 that there was an alcohol based hand rub dispenser less than 6 inches from a grounded electrical plate in the kitchen.