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Based on observation and interview, the facility failed to maintain exits that were readily accessible at all times. Failure to provide exits which are readily accessible at all times could hinder egress during an emergency. This deficient practice affected 9 patients, staff and visitors on the day of the survey. The facility is licensed for 25 hospital beds and had a census of 9 on the day of the survey.

Findings include:

During the facility tour conducted on May 23, 2016 from 11:30 AM to 3:45 PM, observation of the door exiting the 2-hour separation between the southwest corridor and the adjacent building, revealed the door was equipped with a badge-controlled electronic locking arrangement, with internally illuminated sign above it which read: "not an exit". This locking arrangement and signage created a dead-end corridor of approximately ninety (90) feet.

When asked about the locking arrangement and the signage, the Maintenance Manager stated the door exiting this corridor was signed and secured approximately one year prior to the survey to prevent access to the Administration wing in the adjacent building. This finding was confirmed by the Administrator.

Actual NFPA standard:

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

7.1.9 Impediments to Egress.
Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.

7.1.10 Means of Egress Reliability.
7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, the facility failed to ensure that oxygen cylinders were secured in accordance with NFPA 99. Failure to secure high pressure oxygen cylinders could cause damage to cylinders resulting in injury or explosion. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 25 hospital beds and had a census of 9 on the day of the survey.

Findings include:

During the facility tour conducted on May 23, 2016 from approximately 11:30 AM to 3:45 PM, observation of the oxygen cylinders in the piped medical gas equipment and storage area revealed two unsecured (2) "E" cylinders. When asked, the Maintenance Manager stated he was not sure why these cylinders were left unsecured.

Actual NFPA standard:

NFPA 99

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.
(a) * Cylinders or supply containers shall be constructed, tested, and maintained in accordance with the U.S. Department of Transportation specifications and regulations.
(b) Cylinder contents shall be identified by attached labels or stencils naming the components and giving their proportions. Labels and stencils shall be lettered in accordance with CGA Pamphlet C-4, Standard Method of Marking Portable Compressed Gas Containers to Identify the Material Contained.
(c) Contents of cylinders and containers shall be identified by reading the labels prior to use. Labels shall not be defaced, altered, or removed.