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Based on record review and interview with staff, it was determined the facility failed to document the annual testing of the emergency battery backup lights. Failing to maintain emergency lighting units in time of an emergency could cause harm to the patients in an emergency power outage.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

The Facilities Director, Chief Operating Officer (COO) and the surveyor reviewed the documentation for the emergency battery backup lights on June 18, 2019. The documentation reviewed was missing the annual testing for 2018.

The COO acknowledged during the exit conference on June 18, 2019, the emergency battery backup lights were missing the annual testing for 2018.

Based on observation and interview with staff, it was determined the facility failed to provide automatic sprinkler protection throughout the facility. Failing to provide automatic sprinklers to all areas of the facility could potentially cause harm to the patients in time of a fire.

NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.3.5.3 "Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by Section 19.3.5.5." Section 19.3.5.5 "In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where the authority having jurisdiction has prohibited sprinklers, without causing the building to be classified as non-sprinklered. Section 9.7."

Findings include:

The Facilities Director, COO and the surveyor observed on June 18, 2019, that the facility was not provided automatic sprinkler protection throughout the facility. The Mortuary room was missing an automatic sprinkler protection.

The COO acknowledged in the exit conference on June 18, 2019, that the facility was not provided automatic sprinkler protection throughout the facility and the mortuary room failed to have sprinklers..

Based on observation and staff interview, it was determined the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the U.L. Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. Failing to have esutcheon plates in place as part of the sprinkler system poses the potential risk of harm to the patients and staff in the event of a fire if the sprinkler malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 6, Section 6.2.7 "Plates, escutcheons or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler." Section 6.2.7.2* "Escutcheons used with recessed, flush-type , or concealed sprinklers shall be part of a listed sprinkler assembly." Section 6.7.3 "Cover plates used with concealed sprinklers shall be protected with listed guards."

Findings include:

The Facilities Director and the surveyor observed on June 18, 2019, that there was a missing escutcheon plate in the west Labor and Delivery room.

The COO acknowledged during the exit conference on June 18, 2019, that there was a missing escutcheon plate in the west Labor and Delivery room.

Based on observation and interview with staff, it was determined the facility failed to provide protective guards on light bulbs. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause potential harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) "Prevent Physical Damage. In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage."

Findings include:

The Facilities Director, COO and the surveyor observed on June 18, 2019, that there were exposed light bulbs with no protective guards located in the following areas:

1. Electrical Room #1, 12 exposed bulbs.
2. Electrical Room #2, 12 exposed bulbs.
3. Boiler/Chiller rooms, 60 exposed bulbs.
4. Old nursery, 2 exposed bulbs.

The COO acknowledged during the exit conference on June 18, 2019, that there were exposed light bulbs with no protective guards.

Based on record review and interview with staff, it was determined the facility failed to document the testing of the line isolation monitoring. Failing to test the isolated electrical panel units in time of an emergency could potentially cause harm to the patients in an emergency power outage.

NFPA 101 Life Safety Code, 2012, NFPA 99 Health Care Facilities Chapter 6 Section 6.3.3.3 "Isolated Power systems." Section 6.3.4.1 Maintenance and Testing of electrical Systems. Section 6.3.4.1.4" The LIM circuit shall be tested at intervals of not more than one month by actuating the LIM test switch see (6.3.2.6.3.6,) which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4"

Findings include:

The Facilities Director, COO and the surveyor reviewed the documentation for the line isolation monitors on June 18, 2019. The facility failed to document inspections for 2018.

The COO acknowledged during the exit conference on June 18, 2019, the facility failed to document the inspection of the line isolation monitors.

Based on record review and interview with staff, it was determined the facility failed to document the required elements of the weekly visual inspection of the emergency generators. Failure to do weekly visual inspections of the emergency generators could result in potential harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 "Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly." NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...."

Findings Include:

The Facilities Director, COO and the surveyor reviewed the documentation for the emergency generators on June 18, 2019. The documentation onsite only showed some of the required elements for the weekly visual checks. The following weekly visual inspections were missing:

1. January thru March 2018.
2. Three weeks in April 2018.
3. December 2018.
4. January thru April 2019.
5. Three weeks in May 2019.

The COO acknowledged during the exit conference on June 18, 2019, the documentation onsite only showed some of the required elements for the weekly visual checks. There was multiple missing weeks in 2018 and 2019.

Based on observation and interview, it was determined the facility failed to have the light switch and electrical outlets 5 ft above the finished floor in the oxygen storage room. Failing to mount or protect the wall outlet receptacles from physical damage could cause harm to the patients and staff if an oxygen bottle accidentally hits the wall receptacle outlets.

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 99 2012 Edition Standard for Health Care Facilities." Chapter 5 Section 5.1.3.3.2 Design and Construction. Section 5.1.3.3.2 "(5) They shall be in compliance with NFPA 70 National Electrical Code, for ordinary locations. Locations for central supply systems and the storage of positive -pressure gases shall meet the following requirements." Section 5-1.3.3.2 "(5) Electrical devices should be physically protected, such as by use of protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing damage to the cylinders or containers. The device could be located at or above finished floor 1.5 m (5 ft) or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device required by this section." Section 5.1.3.3.2 "(10) They shall protect electrical devices from physical damage."

Findings include:

The Facilities Director, COO and the surveyor observed on June 18, 2019, the light switch and two electrical outlets in the oxygen supply room, located in the PACU, were not a minimum of 5 ft above the finished floor.

The COO acknowledged in the exit confrence on June 18, 2019, that the light switch and two electrical outlets in the oxygen supply room were not 5 ft above the finished floor.