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Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected three of four smoke compartments and could result in the spread of smoke from one area to another in the event of a fire.


Findings:

During the facility tour and interview with Staff 1 and Staff 2, on 3/5/13 and 3/6/13, the ceilings and walls were observed.

3/5/13
1. At 4 p.m., there was an approximately 3/4 by 2 inch penetration on the ceiling of the Chief Nursing Assistant's Office. The penetration was in the left corner of the room. There was an approximately 2 1/2 inch penetration on the right side of the ceiling, in the corner of the room.

3/6/13
2. At 8:45 a.m., there was an approximately 14 by 16 inch damaged area to the left wall in the Tech Central Area, in x-ray, above the baseboard.

At 8:46 a.m., during an interview, Staff 1 reported that this was the result of water damage that occurred approximately about a year ago. He stated that there hasn't been time to repair it.

3. At 8:47 a.m., there was an approximately 1/2 inch penetration below an electrical wall outlet in the x-ray technician's sleeping room. The penetration was on the right wall.

At 8:48 a.m., during an interview, Staff 1 reported there was work done last year and that the sheetrock was cut out too big for the opening of the electrical wall outlet.

4. At 8:55 a.m., there was an approximately two inch penetration around a black cable on the right wall of the ER Med Room.

At 9:21 a.m., during an interview, Staff 1 reported that he cut out the hole to bring through a six plug surge protector through the wall from the other room.

5. At 9:19 a.m., there was a one inch circular penetration in the ceiling in the Dietician's Office. The penetration was around two wires, above the desk area.

6. At 9:20 a.m., there was an approximately three inch round penetration on the ceiling of the autoclave room.

7. At 9:37 a.m., there was an approximately 2 1/2 inch penetration around a 3/4 inch conduit, on the back wall of the equipment storage room. The storage room is between OR 1 and OR 2.

Based on observation and interview, the facility failed to ensure that corridor doors were free from impediments, and that doors close and latch. This was evidenced by six corridor doors that failed to close and latch and by one door that was impeded from closing. This failure could result in the spread of smoke or fire, in the event of a fire, affecting three of four smoke compartments.

Findings:

During the facility tour and interview with Staff 1 on 3/6/13, the corridor doors were observed.

1. At 8:31 a.m., one of two self-closing corridor doors, to the x-ray room, failed to fully close and latch. The door was tested three times.

2. At 9 a.m., the self-closing corridor door to Outpatient Room 1 was impeded from closing by a medical tray. The medical tray was used to hold the door open.

3. At 9:06 a.m., one of two self-closing corridor doors to the kitchen failed to fully close and latch. The door was tested three times.

4. At 9:17 a.m., the self closing corridor door to the restroom, near the dining room, failed to fully close and latch. The door was tested three times.

5. At 9:50 a.m., the corridor door to the OR Surgical Staff Lounge closed but failed to latch. The door was tested four times.

6. At 10:09 a.m., the self closing corridor door to the Physical Therapy Room failed to fully close and latch. The door was tested three times.

7. At 11:27 a.m., the self closing corridor door to the clean linen room, across from Room 112, failed to fully close and latch. The door was tested three times.
At 11:28 a.m., during an interview Staff 1 reported that the striker plate is not the right one.

Based on observation and interview, the facility failed to ensure that the smoke barrier doors are capable of resisting the passage of smoke, and that the doors are self-closing. This was evidenced by one of four smoke barrier doors that failed to close and latch during fire alarm testing. This affected two of four smoke compartments and could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire.

Findings:

During the alarm testing and interview with Staff 1 on 3/5/13, the smoke barrier doors were tested.

At 2:44 p.m., the smoke barrier door between Rooms 107 and 109 did not close and latch after activation of the fire alarm system. The door did not release and remained in the open position.

At 2:45 p.m., during an interview, Staff 1 stated that the door has an oil leak and that he called the vendor last week to come out and service the door.

At 2:50 p.m., the smoke barrier door between Rooms 107 and 109 was tested again. The door did not close and latch after activation of the fire alarm system. The door did not release and remained in the open position.

Based on observation and interview, the facility failed to ensure all staff were trained in fire protection procedures and devices. This was evidenced by staff who did not know the response to a fire alarm trouble signal, and by no records for disaster drills for the past twelve months. This failure affected the entire facility and has the potential to delay evacuation and the potential failure of the sprinkler system if the water supply was shut off.

NFPA 101, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Findings:

During record review and interviews with Staff 1 and Staff 2 on 3/5/13, the records were requested for disaster drills.

1. At 11:02 a.m., the facility provided a disaster drill record titled, "Disaster Drill Sign In Sheet," dated 11/5/06. There were no other records available for review.

At 11:03 a.m., during an interview, Staff 1 stated that there was a disaster drill performed in 2009 but he was unable to produce the records.

During fire alarm and sprinkler system testing, the tamper valve alarm was observed and tested. The tamper alarm is activated when the water valve is closed shutting off the water supply to the sprinkler system.

2. At 3:15 p.m., the water valve was closed, turning off the water supply to the sprinkler system. A tamper alarm sounded in the Nurse's Station. Health care staff in the Nurse's station were asked to identify the alarm signal and the appropriate action when the alarm sounded.

Three of three staff were unable to identify the alarm or had knowledge on the required action. One of three staff stated he believed this alarm had something to do with the plumbing.

At 3:17 p.m., during an interview, all three staff reported they had not been in-serviced on the tamper alarm response.

Based on document review and interview, the facility failed to maintain the fire alarm system. This was evidenced by no records for fire alarm activation confirmed with the monitoring company for seven of twelve months. This had the potential for alarm transmission failure and affected the entire facility.

NFPA 72, 7-3.2, requires the system be tested monthly with Supervising Station.

Findings:

During record review with Staff 1 and Staff 2 on 3/5/13, the records for the monthly activation of the fire alarm system were requested.

At 12:53 p.m., there was no documentation of conducting monthly testing of the fire alarms system confirmed with the monitoring station.

At 12:54 p.m., during interview, Staff 1 stated that he took over this job this week and that the last person who had this job did not activate the alarm on a monthly basis. He reported that he will contact the monitoring company and obtain the documents for the activation for the past 12 months.

On 3/7/13, at approximately 11:17 a.m., records were received from the monitoring company reporting fire alarm signals were received during four of twelve months.

Based on record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by no records for current smoke sensitivity testing. This affected four of four smoke compartments and could result in delayed notification of a fire if a smoke detector was out of range.

NFPA 72 National Fire Alarm Code, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During record review and interview with Staff 1 and Staff 2 on 3/5/13, the smoke detector inspection and test records were requested and reviewed.

At 12:55 p.m., the facility provided a smoke sensitivity record dated 5/11/09, from an outside licensed vendor. There were no other records available for review.

At 12:56 p.m., during an interview, Staff 1 reported there were no other records available for review but that he would contact the vendor to obtain the most current records.

On 3/7/13 at approximately 2:45 p.m., during a telephone interview, Staff 1 reported that he spoke with the vendor who confirmed that the last time the smoke sensitivity testing was performed was on 5/11/09.

Based on observation and interview, the facility failed to ensure maintenance, inspection and testing of the sprinkler system was completed. This was evidenced by three of four quarterly test/inspections that were incomplete, by a tamper valve that was not secure, by a contaminated deflector, and by sprinkler head escutcheon rings that were not flush to the ceiling. An escutcheon ring is used to cover the penetration around the sprinkler pipe. This affected the entire facility and could result in a failure of the sprinkler system in the event of a fire.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition

2-2 Inspection.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

4.3.1 Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request.


Findings:

During the facility tour, with Staff 1 and Staff 2 on 3/5/13 and 3/6/13, the sprinkler system was observed and tested.

3/5/13
1. At 1:18 p.m., there was an approximately 3/4 inch gap between the escutcheon ring and the ceiling in the water heater room, exposing an approximately 1/2 inch penetration.

2. At 1:19 p.m., there was an approximately 1 1/2 by 4 inch penetration on the left side of one of eight sprinkler heads, outside of the ER, on the overhang.
At 1:20 p.m., during an interview, Staff 1 reported that a delivery truck hit and moved the sprinkler head causing the penetration. He stated this took place sometime last year.

3. At 1:25 p.m., two of two sprinkler heads were corroded, on the overhang, outside above the stairs leading to the basement. The sprinkler heads were green.

4. At 1:35 p.m., two of two sprinkler heads were corroded, on the overhang, outside above the dining room. The sprinkler heads were green.

5. At 1:45 p.m., there was an approximately one inch gap between the escutcheon ring and the ceiling, on the overhang outside pre-op.

6. At 3:14 p.m., the tamper valve was not secured with a lock. The lock was laying on top of the tamper valve. The system is facing an alley and is accessible to the public.

At 3:15 p.m., during an interview, Staff 1 reported that the vendor was out about a month ago to service the sprinkler system. He stated he believes the tamper was left unsecured at that time.

7. At 4:27 p.m., one of five sprinkler heads in the Out Patient Registration waiting area was contaminated with paint. The deflector was covered approximately 60 percent with white paint.

At 4:28 p.m., during an interview, Staff 1 reported there was some painting done at the beginning of last year.


3/6/13
8. At 8:31 a.m., the escutcheon ring was not flush to the ceiling in the X-Ray Room 1. There was an approximately 1/2 inch gap between the escutcheon ring and the ceiling, exposing an approximately 1/2 inch penetration around the sprinkler pipe.

9. At 8:37 a.m., the escutcheon ring was not flush to the ceiling in the housekeeping storage room inside the ER. There was an approximately 1/2 inch gap between the escutcheon ring and the ceiling, exposing an approximately 1/2 inch penetration around the sprinkler pipe.

10. At 9:40 a.m., the escutcheon ring was not flush to the ceiling in the Medical Supply Storage Room for the ORs. There was an approximately 1 inch gap between the escutcheon ring and the ceiling, exposing an approximately one inch penetration around the sprinkler pipe.

11. At 9:45 a.m., there was an approximately 1 1/4 inch gap between the escutcheon ring and the ceiling in the OR Janitor's Closet, exposing an approximately 1/8 inch penetration around the sprinkler pipe.

12. At 9:55 a.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling in Room 104, exposing an approximately 1/2 inch penetration around the sprinkler pipe.

13. At 9:59 a.m., there was an approximately 1 1/2 inch gap between the escutcheon ring and the ceiling inside the break room for the pre-op and post-op area, exposing an approximately 1/4 inch penetration around the sprinkler pipe.

14. At 10:10 a.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling inside the Pharmacy Med Room, exposing an approximately one inch penetration around the sprinkler pipe.

During record review, with Staff 1 and Staff 2 on 3/5/13 and 3/6/13, the records for quarterly sprinkler inspection and testing were reviewed.

At 2:22 p.m., the facility provided four testing records titled, "Inspection, Testing, Maintenance Cover Sheet NFPA 25 as Amended by CCR, Title 19." One of four testing records reported the waterflow was tested annually. The records dated 4/20/12, 10/26/12 and 1/28/13 indicated "N/A" for testing the waterflow.

Based on record review and interview, the facility failed to maintain the smoke/fire dampers. This was evidenced by the failure to provide evidence of smoke damper service in accordance with NFPA 101 8.3.4 and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems. This failure affected four of four smoke compartments, and could result in the potential spread of smoke in the event of fire and possible injury to staff and residents.
NFPA 90A
5.4.7 Maintenance. At least every 4 years, the following maintenance shall be performed:
(1) Fusible links (where applicable) shall be removed.
(2) All dampers shall be operated to verify that they close fully.
(3) The latch, if provided, shall be checked.
(4) Moving parts shall be lubricated as necessary.
Findings:

During record review with Staff 1 and Staff 2 on 3/5/13, a request was made to review the most recent smoke damper maintenance service record.

At 1:05 p.m., no record was provided for review.
At 1:06 p.m., during an interview, Staff 1 stated that he was unable to locate any records but will contact the vendor and will request the records.

On 3/7/13, at approximately 2:45 p.m., during a telephone interview, Staff 1 reported that the vendor did not have any records for testing the smoke/fire dampers in the facility.

Based on observation, the facility failed to ensure the storage of medical gas is in accordance with NFPA 99. This was evidenced by oxygen storage room without a sign visible from a distance of 5 feet. This affected one of four smoke compartments and could result in the potential spread of a fire.

NFPA 99
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Findings:

During the facility tour with Staff 1 on 3/6/13, oxygen storage areas were observed.

At 11:23 a.m., there were five E size oxygen cylinders stored in the Utility Room. There was no sign on the door indicating oxygen was stored in the room.

Based on observation, record review, and interview, the facility failed to maintain the diesel generator. This was evidenced by incomplete records for testing at 30% of the diesel generator nameplate rating or at the manufacturers recommended exhaust temperature. There was no record for an annual load bank test. This could result in an increased risk of engine failure and complete loss of electrical power, in the event of a power outage, affecting the entire facility.
NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a
total of 2 continuous hours.
6-4.3 Load tests of generator sets shall include complete cold starts.
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Findings:

During record review and interview with Staff 1 and Staff 2 on 3/5/13, the emergency generator testing records were reviewed.
At 2:27 p.m., the record provided for review was titled "Field Load Test Data Report," dated 12/10/10. The report was from an outside licensed vendor. There was no current record provided for review for an annual load bank test on the diesel emergency generator.
At 2:28 p.m., during an interview, Staff 1 was asked if the emergency generator was tested at 30% of the generator nameplate rating. He stated that he did not know. There were no generator testing records that indicated that the monthly testing was performed at 30% of the nameplate rating.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment. This was evidenced by electrical boxes without cover plates, by appliances and medical equipment connected to surge protectors, by the use of extension cords connected to other extension cords, and by the use of adapters. This affected two of four smoke compartments and could result in an increased risk of an electrical fire.

NFPA 70 National Electrical Code 1999 Edition
400.8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During the facility tour and interview with Staff 1 and Staff 2 on 3/5/13 and on 3/6/13, the electrical wiring and connections were observed.

3/5/13
1. At 10:10 a.m., there were three four by four electrical boxes without covers, exposing electrical wires above the Physical Therapy door. The electrical boxes were above the ceiling, at the attic access.

2. At 10:49 a.m., there was a six plug surge protector connecting a vending machine to the wall outlet in the dinning room. The vending machine contained cold drinks, food that required refrigeration and snacks.

3. At 3:05 p.m., two of two lights indicating the X-Ray Room was in use were illuminated.
At 3:06 p.m., during an interview, Staff 1 reported that the lights are always on, whether the room is in use or not.

4. At 3:49 p.m., there was a brown extension cord plugged into a six plug surge protector that was connected to the electrical wall outlet in the Administration Office Area. The brown extension cord was connected to a small space heater. The six plug surge protector was used for computer equipment.

5. At 4:18 p.m., there was a six plug surge protector used to connect a TV and a microwave to the wall outlet in the Lab.

3/6/13
6. At 8:35 a.m., there was a six plug surge protector used to connect a fan, a TV, and a water cooler to the wall outlet in the ultra sound area.

7. At 8:43 a.m., there was a six plug surge protector plugged into a 10 plug uninterrupted power source underneath the table in the x-ray area. The uninterrupted power source was used to connect computer equipment to the electrical wall outlet.

8. At 8:52 a.m., there was an electrical box inside the X-Ray Office without a cover plate, exposing wires inside the box. The electrical box was at the ceiling adjacent to a light fixture.

9. At 9:08 a.m., there was a six plug surge protector used to connect a large freezer and a radio to a wall outlet in the kitchen.

10. At 9:12 a.m., there was a six plug adapter inside the Doctor's Lounge connected to a space heater.

11. At 9:30 a.m., there was a six plug surge protector used to connect a power box to a CO 2 monitor, a power source that feeds medical equipment, and a EKG monitor in OR 1.

12. At 9:33 a.m., there was a six plug surge protector used to connect OR lights, smoke evacuator/suction, a Bovie, and a EKG monitor in OR 2.

At 9:34 a.m., during an interview, nursing staff reported that the surge is used for charging the items.

13. At 10:07 a.m., there was a mid size refrigerator and a phone charger connected to a six plug surge protector in the ER Doctor's Sleeping Room, near the Physical Therapy Room.

The Fire and Life Safety Inspection Manual states "Extension cords should be used only to connect temporary portable equipment, not as part of permanent wiring. Nor should they be used to supply equipment that will load them beyond their rated capacity."

Based on observation and interview, the facility failed to comply with the installation requirements for Alcohol Based Hand Rub (ABHR) dispensers. This was evidenced by mounting six ABHR dispensers above and adjacent to an ignition source. Staff and residents could potentially be harmed from a static discharge and a fire. This affected three of four smoke compartments in the facility.

Findings:

During the facility tour with Staff 1 and Staff 2 on 3/5/13 and on 3/6/13, the ABHR dispensers were observed.

3/5/13
1. At 2:32 p.m., there was an ABHR dispenser in the reception area, mounted above the copy machine. The hand rub was sixty-two percent ethyl alcohol by volume.

2. At 2:48 p.m., the pre-op/recovery area had an ABHR dispenser mounted two inches adjacent to a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

3. At 4:15 p.m., the storage room, across the hall from the clinic, had an ABHR dispenser mounted three inches adjacent to a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

3/6/13
4. At 8:32 a.m., there was an ABHR dispenser in X-Ray Room 2, mounted above and one inch adjacent to a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

5. At 9:35 a.m., there was an ABHR dispenser in OR 2, mounted four inches adjacent to a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

6. At 10:02 a.m., there was an ABHR dispenser outside Room 109 that was mounted on the wall approximately three inches adjacent to the light switch. The hand rub was sixty-one percent ethyl alcohol by volume.