HospitalInspections.org

Based on observation during the survey walk-through, not all egress doors are installed to permit egress from the building at al times. This deficiency could affect any occupants of the Patio by preventing them from exiting the building under emergency conditions.

Findings include:

On January 10, 2017 at 1:40 PM, while accommodated by the DPO, it was observed that the door from the Center Wing exterior Patio can be secured against egress (back into the building) as prohibited by 7.2.1.5.1.

Based on observation during the survey walk-through, not all egress paths are properly identified by exit signs. These deficiencies could affect any patients, staff, or visitors in the area by preventing them from exiting the building under emergency conditions.

Findings include:

A. On January 10, 2017 at 12:53 PM, while accompanied by the DPO, it was observed that the north end of the Center Wing east North-South Corridor lacked an exit sign required by 7.10.1.1.

B. On January 10, 2017 at 1:22 PM, while accompanied by the DPO, it was observed that the west door from the Brain Injury Unit Service Corridor, which is secured against egress toward the west, is equipped with an exit sign as prohibited by 7.10.1.1.

Based on observation during the survey walk-through, the enclosures for all hazardous areas are not complete as required. These deficiencies could affect any patients, staff, or visitors in the area because fire and smoke could move from them to other occupied portions of the building.

Findings include:
While accompanied by the DPO, pipe penetrations were observed that are not sealed against the passage of fire as required by 19.3.2.1 and 8.3.5.1. Locations observed include:
A. January 10, 2017, 12:41 PM: Center Wing EVS Room, above ceiling in east wall, 1 pipe.

B. January 10, 2017, 1:17 PM: Brain Injury Unit Nurse Station Storage Room, southwest wall, 1 pipe.

Based on observation during the survey walk-through, not all components of the fire alarm system are installed as required. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system could fail to activate in a timely manner.

Findings include:

On January 10, 2017 at 1:36 PM, while accompanied by the DPO, portions of the ceiling in the Brain Injury Unit Telephone/Data Room were observed to be out of place, thus compromising detection of the space by the smoke detector located there in a manner prohibited by NFPA 72 2010 17.7.3.2.1.

Based on observation during the survey walk-through, not all components of the automatic sprinkler system are installed as required. This deficiency could affect any patients, staff, or visitors in the building because the sprinkler system could fail to activate in a timely manner.

Findings include:

On January 10, 2017 at 1:36 PM, while accompanied by the DPO, portions of the ceiling in the Brain Injury Unit Telephone/Data Room were observed to be out of place, thus compromising sprinkler coverage of the space by the smoke detector located there in a manner prohibited by NFPA 13 2010 8.6.4.1.1.



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Based on direct observation the facility failed to install compliant building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

On 1/11/2017 at 9:15 AM in the company of the SMM it was observed the lack of complete enclosure of the electrical closet accessed through the environmental services closet across, from Speech Therapy. The walls are incomplete allowing heat to dissipate to the interstitial space above the adjacent ceilings delaying activation of the installed sprinkler head. NFPA 13. 2010. 8.15.22

Based on observation during the survey walk-through, not all corridor doors are installed and maintained as required. This deficiency could affect any patients, staff, or visitors in the area because fire and smoke could pass into the corridor.

Findings include:

On January 11, 2017, at 8:41 AM, while accompanied by the DPO, the active leaf of the north door to the Therapy Pool was observed to not be positive latching as required by 19.3.6.3.5.

Based on document review, not all fire drills are conducted in the manner required. This deficiency could affect any patients, staff, or visitors in the building because the staff could fail to react as required under emergency conditions.

Findings include:

On January 10, 2017, at 2:30 PM, while accompanied by the DPO, it was determined from fire drill records that the times for Second Shift Fire Drills do not vary as required by 19.7.1.6. Second Shift Fire Drills were conducted at the similar times listed below:

A. March 1, 2016: 7:35 PM.

B. June 22, 2016: 7:35 PM.

C. July 20, 2016: 7:15 PM.

D. November 29, 2016: 7:30 PM.

Based on observations and interviews the facility failed to provide a compliant electrical system. This deficient practice could affect patients, staff and visitors during a power outage if the electrical system did not function properly.
Findings include:
A. On 1/11/17 at 9:15 AM, while accompanied by the SMM, it was observed that life safety panel EL was serving a circulating pump. Only the loads listed in the 2012 Edition of NFPA-99, Section 6.4.2.2.3.2 are allowed to be served from the life safety branch of emergency power.