Nursing Investigation Results -

Pennsylvania Department of Health
LECOM AT PRESQUE ISLE, INC.
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LECOM AT PRESQUE ISLE, INC.
Inspection Results For:

There are  31 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
LECOM AT PRESQUE ISLE, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on August 29, 2019, at Lecom at Presque Isle, Inc., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.






 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID # 530402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 29, 2019, it was determined that Lecom at Presque Isle, Inc., was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected. noncombustible building, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, the facility failed to maintain portable fire extinguishers for one of over ten fire extinguishers.

Findings include:

1. Observation on August 29, 2019, at 11:30 a.m., revealed the kitchen ABC fire extinguisher (left side of cooking units), was blocked with a large plastic container.

Interview with the maintenance director on August 29, 2019, at 11:30 a.m., confirmed the above fire extinguisher was blocked.



 Plan of Correction - To be completed: 10/23/2019

8/29/19 the plastic container was removed from in front of the ABC fire extinguisher (left side of cooking units) to insure clear access to the extinguisher.

All dietary staff was educated to ensure that the fire extinguisher is accessible at all times

To ensure that all extinguishers remain accessible and free of obstruction the following will occur:

An audit of all dietary fire extinguishers was conducted 8/29/19 to ensure that they are free of obstruction
Ongoing, daily audits of all dietary extinguishers will be completed and will be the responsibility of the Maintenance Director or designee

An all staff education will be conducted by Maintenance Director in conjunction with Staff Educator no later than 9/20/19 to not place items in front of extinguishers

Results of the audits will be presented at the monthly QA meeting for review.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on observation and interview, the facility failed to maintain essential electrical systems for one of two emergency generators.

Findings include:

1. Observation on August 29, 2019, at 8:45 a.m., revealed the surveyor, maintenance director and administrator observed the strong noxious smell of the #2 outside diesel generator (located next to the outside wall of resident rooms #34 - 48), during the weekly load test of the unit.

2. Interview on August 29, 2019, at 10:45 a.m., with the resident in room #34-2 (with the help of an interpreting nurses aide), revealed the resident had concerns with the fumes that enter his room during weekly emergency generator run tests of unit #2.

3. Observation on August 29, 2019, at 12:30 p.m., revealed the surveyor measured the distance from the emergency generator exhaust to an intake within the building. The distance measured was 17 feet.
a. The American Institute of Architects, Academy of Architecture for Health, Guidelines for Design and Construction of Hospital and Health Care Facilities indicate, "fresh air intakes shall be located at least 25 feet from exhaust outlets of...combustion equipment stacks..or areas that may collect vehicular exhaust or other noxious fumes. (Prevailing winds and/or proximity to other structures may require greater clearances.)"
b. NFPA 110, 2010 edition 7.10.2, "Exhaust system installation shall be gastight to prevent exhaust gas fumes from entering inhabited rooms or buildings and terminate in such a manner that toxic fumes cannot reenter a building or structure, particularly through windows, air ventilation inlets, or the engine air-intake system.

4. Observation on August 29, 2019, at 1:00 p.m., revealed resident rooms on wing #34 - #48 lacked carbon monoxide (CO) detectors in every room to alert the facility staff of possible CO from the emergency generator #2 exhaust fumes.

Interview with the maintenance director and administrator on August 29, 2019, at 1:30 p.m., confirmed the exhaust outlet for emergency generator #2 shall be above roof level, and arranged to minimize recirculation of exhaust air into the building.







 Plan of Correction - To be completed: 10/23/2019

To ensure that the fumes from the exhaust outlet for the emergency generator #2 do not permeate into the building, the following will occur:
Generator #2 exhaust outlet will be extended to above roof level.

Contractor was at facility 9/9/19 to assess generator for extension of the stack

CO2 detectors will be installed in resident rooms that may be affected by the exhaust outlet of generator #2
An audit will be completed by Maintenance Director or designee weekly for 1 month and monthly ongoing to ensure CO2 detectors are functioning properly.

Staff will be educated by Staff Educator in conjunction with Maintenance Director, no later than 9/20/19 to identify when and process for CO2 detectors when they are activated

Results of the audit will be presented at the monthly QA meeting for review

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power cord regulations in one of over fifty rooms.

Findings include:

1. Observation on August 29, 2019, at 12:50 p.m., revealed resident room #12, had a nebulizer (medical equipment) plugged into a surge protector.

Interview with the maintenance director on August 29, 2019, at 12:50 p.m., confirmed the above medical equipment was not plugged directly into an electrical receptacle.





 Plan of Correction - To be completed: 10/23/2019

To ensure that Nebulizers are plugged into appropriate electrical receptacles, the following will action plan will occur:

Nebulizer in room #12 was unplugged from power strip and plugged into wall on 8/29/19.

Contractors, Church & Murdock are scheduled to change electrical outlet from two plug outlet to a four plug outlet 9/11/19.

Facility wide audit was conducted 8/29/19 to ensure no medical equipment more specifically nebulizers were plugged into surge protectors.

Staff will be educated by Staff Educator no later than 9/20/19 regarding appropriate electrical receptacle to plug nebulizer or medical equipment

An audit will be completed by
Maintenance Director or designee daily for 2 weeks and monthly ongoing, to ensure that nebulizers are plugged into the appropriate electrical outlets.

Results of the audit will be presented at the monthly QA meeting for review

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to maintain medical gas cylinder storage on one of six wings.

Findings include:

1. Observation on August 29, 2019, at 10:45 a.m., revealed the oxygen transfilling room had two unsecured e-type oxygen cylinders.

Interview with the maintenance director on August 29, 2019, at 10:45 a.m., confirmed the above oxygen storage room had two unsecured cylinders.




 Plan of Correction - To be completed: 10/23/2019

To ensure that medical gas cylinder storage is properly maintained, the following will occur:

8/29/19 Oxygen cylinders were immediately secured in the provided cylinder holders.

Maintenance Director in conjunction with Staff Educator will provide staff in service regarding proper storage of oxygen cylinders. Education will be held no later than 9/20/19

An audit will be completed daily ongoing, by the Maintenance Director or designee to ensure proper storage of oxygen cylinders

Results of the audits will be presented at the monthly QA meeting for review


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