HospitalInspections.org

Based on observation and staff interview, the facility failed to install and maintain doors protecting corridor openings to resist the passage of smoke, in the event of fire, as required.

Findings include:

1. On 05/14/12, the first day of survey, observation during the interior tour of B-Wing from 1:00 p.m. to 3:45 p.m. revealed double-leaf patient room doors in B420, B410, B369, B360, B359, B469, B460, B450, B511, B510, and B501 when closed with a gap of greater than 1/8 inch to 1/2 inch between the double doors thereby permitting the passage of smoke in the event of fire.

The Assistant Director of Engineering confirmed each of the door observations.


2. On 05/16/12, the third day of survey, observation during the interior tour of M-Wing from 10:30 a.m. to 3:00 p.m. revealed double-leaf patient room doors in M311 and M339 when closed with a gap of greater than 1/8 inch to 1/2 inch between the double doors thereby permitting the passage of smoke in the event of fire.

The Assistant Director of Engineering confirmed each of the door observations.

NFPA 101, (2000 Edition), 19.3.6.3.

Based on observation and staff interview, the facility failed to maintain exit access by "locking out" the delayed-egress lock and preventing readily accessible exit access at all times as required.

Findings include:

1. Observation on 05/14/12, accompanied by facility representatives, of the fourth floor door 174, a door labeled as an "Exit" in B-Wing revealed signage on the door stating "Push until alarm sounds, door can be opened in 15 seconds". Upon closing of the double corridor smoke doors and testing of the "Push until alarm sounds, door can be opened in 15 seconds" at 10:45 a.m., the locks failed to release after a force of greater than 30 lbf, (foot pounds) was applied and sustained for 35 seconds. Upon use, by a facility employee, of the security card swipe adjacent to the door the locking devise released indicating that door 174, at the time of test, was programmed to "lock out" and prevent the use of the approved 15 second delayed-egress function.

2. On 05/14/12 the Assistant Director of Engineering confirmed the observation of the failed push to test. Interview of the Nursing Manager of the 4th floor Nursing Unit revealed the security card swipe was required to enter the Nursing Unit from the core elevator service area of B-Wing at night and after visiting hours, thereby "locking out" exit access through door 174 that was labeled as an "Exit" and overriding the approved delayed-egress function.

NFPA 101, (2000 Edition), 7.1, 7.2.1, 7.2.1.6 and 19.2.1.

Based on record review and staff interview, the facility failed to ensure staff were trained in emergency fire procedures, consisting of at least one fire drill per shift per quarter as required by NFPA 101, (2000) 19.7.1.2. Each laboratory staff member must participate, at least annually, in one of the required laboratory quarterly fire drills as required by NFPA 99, (1999),10-2.1.4.3. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

Findings include:

1. On 05/14/12 record review from 10:30 a.m. to 1:00 p.m. revealed documentation of hospital fire drills conducted each shift per quarter. There was no documentation available listing personnel, such as "nurses, interns, maintenance engineers, and administrative staff" participating in fire drills for the previous four quarters thereby preventing the determination that employees are familiar with signals and emergency action at varying times and under varied conditions.

Interview of facility personnel responsible for conducting fire drills revealed there was no process, on the day of survey, for documenting the personnel attending and participating in required quarterly fire drills.

2. During record review and staff interviews of the laboratory survey on 05/16/12, the facility could not provide documentation that the required laboratory quarterly fire drills had been conducted and that each laboratory staff member participated in at least one laboratory fire drill per year. The director of the laboratory stated personnel are trained once a year.

NFPA 101, (2000) 19.7.1.2
NFPA 99 (1999 edition) 10-2.1.4.3*

Based on observations and staff interviews it was determined the facility did not comply with specific requirements of NFPA 70, the National Electrical Code and the NFPA 99.

Findings include:

1. During the facility tour with the Chief Operating/Chief Nursing Officer and Director of Maintenance at 2:30 p.m. on 05/16/12 it was observed in the PAC unit office that a multi-plugged device was plugged into other multi-plugged device that was plugged into other multi-plugged device and was in use. The equipment in use was various computers and office equipment.

2. During the facility tour with the Chief Operating/Chief Nursing Officer and Director of Maintenance it was observed that an extension cord was in use. A microwave was plugged into the extension cord. The was observed at 1:45 p.m. on 05/16/12 in the Director of Nursing Secretary room.

3. On 05/16/12, the third day of survey, observation during the interior tour from 10:30 a.m., to 3:30 p.m. revealed in the Business Office under a table next to the copy machine a multi-plugged device plugged into an orange extension cord that was in use.

NFPA 101 (2000 edition):
NFPA 99 (1999 edition) 8.5.2.1.7.
NFPA 70 National Electric Code.

Based on observation and staff interview, the facility failed to install and maintain doors protecting corridor openings to resist the passage of smoke, in the event of fire, as required.

Findings include:

1. On 05/14/12, the first day of survey, observation during the interior tour of B-Wing from 1:00 p.m. to 3:45 p.m. revealed double-leaf patient room doors in B420, B410, B369, B360, B359, B469, B460, B450, B511, B510, and B501 when closed with a gap of greater than 1/8 inch to 1/2 inch between the double doors thereby permitting the passage of smoke in the event of fire.

The Assistant Director of Engineering confirmed each of the door observations.


2. On 05/16/12, the third day of survey, observation during the interior tour of M-Wing from 10:30 a.m. to 3:00 p.m. revealed double-leaf patient room doors in M311 and M339 when closed with a gap of greater than 1/8 inch to 1/2 inch between the double doors thereby permitting the passage of smoke in the event of fire.

The Assistant Director of Engineering confirmed each of the door observations.

NFPA 101, (2000 Edition), 19.3.6.3.

Based on observation and staff interview, the facility failed to maintain exit access by "locking out" the delayed-egress lock and preventing readily accessible exit access at all times as required.

Findings include:

1. Observation on 05/14/12, accompanied by facility representatives, of the fourth floor door 174, a door labeled as an "Exit" in B-Wing revealed signage on the door stating "Push until alarm sounds, door can be opened in 15 seconds". Upon closing of the double corridor smoke doors and testing of the "Push until alarm sounds, door can be opened in 15 seconds" at 10:45 a.m., the locks failed to release after a force of greater than 30 lbf, (foot pounds) was applied and sustained for 35 seconds. Upon use, by a facility employee, of the security card swipe adjacent to the door the locking devise released indicating that door 174, at the time of test, was programmed to "lock out" and prevent the use of the approved 15 second delayed-egress function.

2. On 05/14/12 the Assistant Director of Engineering confirmed the observation of the failed push to test. Interview of the Nursing Manager of the 4th floor Nursing Unit revealed the security card swipe was required to enter the Nursing Unit from the core elevator service area of B-Wing at night and after visiting hours, thereby "locking out" exit access through door 174 that was labeled as an "Exit" and overriding the approved delayed-egress function.

NFPA 101, (2000 Edition), 7.1, 7.2.1, 7.2.1.6 and 19.2.1.

Based on record review and staff interview, the facility failed to ensure staff were trained in emergency fire procedures, consisting of at least one fire drill per shift per quarter as required by NFPA 101, (2000) 19.7.1.2. Each laboratory staff member must participate, at least annually, in one of the required laboratory quarterly fire drills as required by NFPA 99, (1999),10-2.1.4.3. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

Findings include:

1. On 05/14/12 record review from 10:30 a.m. to 1:00 p.m. revealed documentation of hospital fire drills conducted each shift per quarter. There was no documentation available listing personnel, such as "nurses, interns, maintenance engineers, and administrative staff" participating in fire drills for the previous four quarters thereby preventing the determination that employees are familiar with signals and emergency action at varying times and under varied conditions.

Interview of facility personnel responsible for conducting fire drills revealed there was no process, on the day of survey, for documenting the personnel attending and participating in required quarterly fire drills.

2. During record review and staff interviews of the laboratory survey on 05/16/12, the facility could not provide documentation that the required laboratory quarterly fire drills had been conducted and that each laboratory staff member participated in at least one laboratory fire drill per year. The director of the laboratory stated personnel are trained once a year.

NFPA 101, (2000) 19.7.1.2
NFPA 99 (1999 edition) 10-2.1.4.3*

Based on observations and staff interviews it was determined the facility did not comply with specific requirements of NFPA 70, the National Electrical Code and the NFPA 99.

Findings include:

1. During the facility tour with the Chief Operating/Chief Nursing Officer and Director of Maintenance at 2:30 p.m. on 05/16/12 it was observed in the PAC unit office that a multi-plugged device was plugged into other multi-plugged device that was plugged into other multi-plugged device and was in use. The equipment in use was various computers and office equipment.

2. During the facility tour with the Chief Operating/Chief Nursing Officer and Director of Maintenance it was observed that an extension cord was in use. A microwave was plugged into the extension cord. The was observed at 1:45 p.m. on 05/16/12 in the Director of Nursing Secretary room.

3. On 05/16/12, the third day of survey, observation during the interior tour from 10:30 a.m., to 3:30 p.m. revealed in the Business Office under a table next to the copy machine a multi-plugged device plugged into an orange extension cord that was in use.

NFPA 101 (2000 edition):
NFPA 99 (1999 edition) 8.5.2.1.7.
NFPA 70 National Electric Code.