HospitalInspections.org

Based on observation and staff interview, the facility failed to provide a self-closing and positive latching fire door in a two-hour fire barrier. This condition would allow fire to migrate to other areas of the facility.

Findings are:
Observation during the facility tour on 6/16/15, at 1:13 pm revealed the 90-minute fire rated Dining Room Door that was located in a two-hour fire barrier had a kick-down door hold open device installed at the bottom of the door, and the door failed to self-close and positive latch.
In an interview conducted at the time of observation, (6/16/15, at 1:13 pm), Maintenance A confirmed the door failed to self-close and positive latch.

Based on observation and staff interview, the facility failed to secure an oxygen bottle to prevent the bottle from tipping over. This condition had the potential to cause an injury to a patient.

Findings are:
Observation during the facility tour on 6/16/15, at 1:21 pm revealed an oxygen bottle in Jody ' s Office failed to be secured, and was freestanding in the room.
In an interview conducted at the time of observation, (6/16/15, at 1:21 pm), Maintenance A acknowledged the oxygen bottle failed to be secured.

Actual NFPA Standard:
NFPA 99, 1999 ed, 4-3.1.1* Source - Level 1.
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on record review and staff interview, the facility failed to maintain humidity levels in the operating room in accordance with the National Fire Protection Association 99 throughout the last year. This condition created the potential for a burn or fire to occur during a procedure.

Findings are:
Record review during the facility tour on 6/16/15, at 1:42 pm revealed humidity levels failed to be maintained at a minimum of 35% consistently throughout the last 12 months during procedures in the OR.
In an interview conducted at the time of record review, (6/16/15, at 1:42 pm), Maintenance A acknowledged the humidity levels recorded failed to consistently be at 35% or greater for the past year.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 6/16/15, at 1:48 pm of the provided emergency generator maintenance revealed the documentation failed to exhibit information for monthly testing in accordance with NFPA 110:
1. Documentation that the generator picked up the emergency system load within 10 seconds after loss of normal power failed to be recorded.
2. The percentage of KW that the generator ran at during monthly load testing failed to be documented.
In an interview conducted at the time of record review, (6/16/15, at 1:48 pm), Maintenance A confirmed that the generator testing documentation failed to be completed.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
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.
NFPA 99, 1999, 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association 70. This condition had the potential to cause an electrical fire.

Findings are:
Observation during the facility tour on 6/16/15, at 12:05 pm revealed a microwave was plugged into a power strip in the Nurse Supply Room, and the heat producing appliance failed to be plugged directly into a wall outlet.
In an interview conducted at the time of observation (6/16/15, at 12:05 pm), Maintenance A acknowledged the findings.