HospitalInspections.org

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the doors closed and resistant to the passage of smoke.

Observation determined the double set of corridor doors to the Special Care Unit Storage Closet on the second floor were not automatic latching. The secondary door was equipped with a manual latching lever.

Failure to ensure corridor doors are provided with automatic latching hardware increases the risk for death or injury due to fire.

This deficiency affected one (1) of numerous corridor doors in the facility.

The facility failed to maintain the one-hour fire resistive rating of shaft enclosures throughout the building.

Observation determined:
1) There were five (5) unsealed cable penetrations through the East Stairway wall to the corridor on the second floor above the suspended ceiling.
2) The corridor wall above the ceiling on the second floor to the elevator shaft had a 3-inch hole in the clay block.
3) There were two (2) unsealed electrical conduit penetrations and a 2-inch hole located above the suspended ceiling in the block wall separating the North Stairway from the corridor on the second floor.

Failure to maintain a one-hour fire resistant rating of vertical openings increases the risk of death or injury due to fire.

This deficiency affected three (3) of seven (7) vertical shafts in the facility.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.
Observation determined:

1) The door to the Second Floor West Wing Soiled Linen Room did not have self-closing hardware.

2) The door to the First Floor Soiled Linen Room next to the Laundry Room failed to self-close and latch when tested.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous hazardous areas in the facility.

The facility failed to ensure exit access was readily accessible at all times.

Observation determined:

1) Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge. 7.7.2

The facility failed to arrange at least 50 percent of exits to discharge directly to the exterior of the building.

The North, East, and Center stairways from the second floor discharged onto the first floor and did not exit directly to the outside.

This deficiency affected three (3) of four (4) designated exits from the second floor.

2) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.4.

The following corridor doors opened outward into the exit corridor and extended more than seven inches from the wall when fully opened:

1) The Trash Chute Room on the first floor.
2) The Medical Chute Room on the first floor.
3) The West Wing Storage Room on the second floor.
4) The East Wing Janitor Closet on the second floor.

This deficiency affected four (4) of numerous corridor doors in the means of egress throughout the facility.

3) Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

The facility failed to provide hard surfaces from all required exits to public ways.

Observation determined the exit from the West Wing traversed the lawn to get to a public way.

The deficiency affected one (1) of four (4) required exits from the building.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.

The facility failed to ensure patient rooms were arranged such that the patient can open the door from the inside without using a key.

Observation determined the glass sliding corridor doors to Emergency Rooms 1, 2, 3, and 4 were equipped with a key operated manual dead-bolt lock.

Failure to ensure patients can open room doors from the inside without the use of a key increases the risk of death or injury due to fire.

This deficiency affected four (4) of numerous patient room corridor doors throughout the facility.

The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. 7.10.1.2

Observation determined the exit signage located at the east stair enclosure directed exiting into an enclosed courtyard. The second door which did lead to an approved exit was not marked with appropriate signage.

Failure to provide exit signage as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of four (4) exits from the second floor.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most currect record of the fire alarm system batteries load voltage test was done by an outside company during the annual inspection on 04/08/2015, exceeding six months to the date of this survey.

Failure to test and maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler. NFPA 13 5-5.3.4

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined two (2) sprinklers in the Physical Therapy Treatment Room and two (2) sprinklers in the Medical Chute Room were closer than the minimum of six feet apart.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected two (2) of numerous locations protected by the automatic sprinkler system, which serves the entire facility.

The facility failed to install supervisory attachments on the automatic sprinkler system to monitor for integrity in accordance with NFPA 72, National Fire Alarm Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1.

Observation determined the sprinkler pipe valve between the antifreeze system and the wet pipe system in the Kitchen was not electronically monitored.

Failure to monitor sprinkler system control valves increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous control valves on the automatic sprinkler system. The automatic sprinkler system serves the entire building.

The facility failed to keep means of egress free of obstructions.

Observation determined a 3-inch electrical conduit crossed the sidewalk from the building to service equipment in the exit discharge from the west exit.

Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire.

This deficiency affected exit access from one (1) of four (4) exits from the second floor.

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the doors closed and resistant to the passage of smoke.

Observation determined the double set of corridor doors to the Special Care Unit Storage Closet on the second floor were not automatic latching. The secondary door was equipped with a manual latching lever.

Failure to ensure corridor doors are provided with automatic latching hardware increases the risk for death or injury due to fire.

This deficiency affected one (1) of numerous corridor doors in the facility.

The facility failed to maintain the one-hour fire resistive rating of shaft enclosures throughout the building.

Observation determined:
1) There were five (5) unsealed cable penetrations through the East Stairway wall to the corridor on the second floor above the suspended ceiling.
2) The corridor wall above the ceiling on the second floor to the elevator shaft had a 3-inch hole in the clay block.
3) There were two (2) unsealed electrical conduit penetrations and a 2-inch hole located above the suspended ceiling in the block wall separating the North Stairway from the corridor on the second floor.

Failure to maintain a one-hour fire resistant rating of vertical openings increases the risk of death or injury due to fire.

This deficiency affected three (3) of seven (7) vertical shafts in the facility.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.
Observation determined:

1) The door to the Second Floor West Wing Soiled Linen Room did not have self-closing hardware.

2) The door to the First Floor Soiled Linen Room next to the Laundry Room failed to self-close and latch when tested.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous hazardous areas in the facility.

The facility failed to ensure exit access was readily accessible at all times.

Observation determined:

1) Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge. 7.7.2

The facility failed to arrange at least 50 percent of exits to discharge directly to the exterior of the building.

The North, East, and Center stairways from the second floor discharged onto the first floor and did not exit directly to the outside.

This deficiency affected three (3) of four (4) designated exits from the second floor.

2) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.4.

The following corridor doors opened outward into the exit corridor and extended more than seven inches from the wall when fully opened:

1) The Trash Chute Room on the first floor.
2) The Medical Chute Room on the first floor.
3) The West Wing Storage Room on the second floor.
4) The East Wing Janitor Closet on the second floor.

This deficiency affected four (4) of numerous corridor doors in the means of egress throughout the facility.

3) Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

The facility failed to provide hard surfaces from all required exits to public ways.

Observation determined the exit from the West Wing traversed the lawn to get to a public way.

The deficiency affected one (1) of four (4) required exits from the building.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.

The facility failed to ensure patient rooms were arranged such that the patient can open the door from the inside without using a key.

Observation determined the glass sliding corridor doors to Emergency Rooms 1, 2, 3, and 4 were equipped with a key operated manual dead-bolt lock.

Failure to ensure patients can open room doors from the inside without the use of a key increases the risk of death or injury due to fire.

This deficiency affected four (4) of numerous patient room corridor doors throughout the facility.

The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. 7.10.1.2

Observation determined the exit signage located at the east stair enclosure directed exiting into an enclosed courtyard. The second door which did lead to an approved exit was not marked with appropriate signage.

Failure to provide exit signage as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of four (4) exits from the second floor.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most currect record of the fire alarm system batteries load voltage test was done by an outside company during the annual inspection on 04/08/2015, exceeding six months to the date of this survey.

Failure to test and maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler. NFPA 13 5-5.3.4

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined two (2) sprinklers in the Physical Therapy Treatment Room and two (2) sprinklers in the Medical Chute Room were closer than the minimum of six feet apart.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected two (2) of numerous locations protected by the automatic sprinkler system, which serves the entire facility.

The facility failed to install supervisory attachments on the automatic sprinkler system to monitor for integrity in accordance with NFPA 72, National Fire Alarm Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1.

Observation determined the sprinkler pipe valve between the antifreeze system and the wet pipe system in the Kitchen was not electronically monitored.

Failure to monitor sprinkler system control valves increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous control valves on the automatic sprinkler system. The automatic sprinkler system serves the entire building.

The facility failed to keep means of egress free of obstructions.

Observation determined a 3-inch electrical conduit crossed the sidewalk from the building to service equipment in the exit discharge from the west exit.

Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire.

This deficiency affected exit access from one (1) of four (4) exits from the second floor.