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Based on observations, the facility has failed to provide proper protection from hazardous areas in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect residents on the 2nd floor. This deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 12:30 PM on 4/23/12 and 4:00 PM on 4/24/12, it was observed that:

The following rooms have been changed from patient rooms to storage rooms and their corridor doors are not self-closing on the 2nd floor.

Rooms observed were 2206, 2201 and 2317.

Based on observation, the facility has failed to provide proper exit hardware on exit doors to the stairwell exit access doors. This deficient practice could affect the safe and rapid evacuation of all residents, visitors and staff in the event of an emergency that may require quick evacuation.

Findings include:
On facility tour between 12:30 PM on 4/23/12 and 4:00 PM on 4/24/12, it was observed that:

1) The OB main entrance door on the 2nd floor is locked against egress and is not does not meet NFPA 101 section 7.2.1.6.1 (15 second delayed egress),

2) The following exit and exit access doors from the 2nd floor have 15 second delay locks but the doors are not labeled PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS:
1. East stairway exit door,
2. The OB north stairway exit door, and
3. The OB south west cross corridor door ' s.

Based on review of the fire emergency plan and observation by MDH surveyors, the facility has failed to follow the requirements of their Patient Fire Safety plan in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients, staff and visitors of the smoke compartment that may be affected by a fire.

It was observed by MDH surveyors (MW and KH) that on Tuesday 4/24/12 at 11:50 AM during a surgery procedure in OR #4, the long cautery wand L Hook Electrode, was placed on the patient drape instead of placing it in the holster.

This is in violation of the hospital policy for Patient Fire Safety: Oxygen Enriched Environment dated 2/2012.



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Based on record review and interview, it was determined that the facility failed to provide quarterly fire drills in a manner required in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire, Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12:30 PM and 04:00 PM on 04/23/2012, the fire drill records revealed and an interview with the facility Director of Facility Services (CS) confirmed that quarterly fire drills are conducted, however, the times are not varied throughout the shift during the evening shift drills. All drills are conducted between 3:04 PM and 4:16 PM,

Based on record review and interview, it was determined that the facility failed to provide quarterly fire drills in a manner required in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire, Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12:30 PM and 04:00 PM on 04/23/2012, fire drill records revealed and an interview with the facility Director of Facility Services (CS) confirmed that the quarterly fire drills are conducted, however, the times are not varied throughout the shift during the evening shift drills. All drills are conducted between 3:04 PM and 4:16 PM,

Based on observation, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:
On facility tour between 12:30 PM on 4/23/12 and 4:00 PM on 4/24/12, it was observed that the 2nd floor wall mounted, fold down writing desks and fold down computer work stations located near rooms 221 and 2200 did not retract as designed when tested.

Based on observations, the facility has failed to provide proper protection from hazardous areas in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect residents on the 2nd floor. This deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 12:30 PM on 4/23/12 and 4:00 PM on 4/24/12, it was observed that:

The following rooms have been changed from patient rooms to storage rooms and their corridor doors are not self-closing on the 2nd floor.

Rooms observed were 2206, 2201 and 2317.

Based on observation, the facility has failed to provide proper exit hardware on exit doors to the stairwell exit access doors. This deficient practice could affect the safe and rapid evacuation of all residents, visitors and staff in the event of an emergency that may require quick evacuation.

Findings include:
On facility tour between 12:30 PM on 4/23/12 and 4:00 PM on 4/24/12, it was observed that:

1) The OB main entrance door on the 2nd floor is locked against egress and is not does not meet NFPA 101 section 7.2.1.6.1 (15 second delayed egress),

2) The following exit and exit access doors from the 2nd floor have 15 second delay locks but the doors are not labeled PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS:
1. East stairway exit door,
2. The OB north stairway exit door, and
3. The OB south west cross corridor door ' s.

Based on review of the fire emergency plan and observation by MDH surveyors, the facility has failed to follow the requirements of their Patient Fire Safety plan in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients, staff and visitors of the smoke compartment that may be affected by a fire.

It was observed by MDH surveyors (MW and KH) that on Tuesday 4/24/12 at 11:50 AM during a surgery procedure in OR #4, the long cautery wand L Hook Electrode, was placed on the patient drape instead of placing it in the holster.

This is in violation of the hospital policy for Patient Fire Safety: Oxygen Enriched Environment dated 2/2012.



.

Based on record review and interview, it was determined that the facility failed to provide quarterly fire drills in a manner required in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire, Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12:30 PM and 04:00 PM on 04/23/2012, the fire drill records revealed and an interview with the facility Director of Facility Services (CS) confirmed that quarterly fire drills are conducted, however, the times are not varied throughout the shift during the evening shift drills. All drills are conducted between 3:04 PM and 4:16 PM,

Based on record review and interview, it was determined that the facility failed to provide quarterly fire drills in a manner required in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire, Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12:30 PM and 04:00 PM on 04/23/2012, fire drill records revealed and an interview with the facility Director of Facility Services (CS) confirmed that the quarterly fire drills are conducted, however, the times are not varied throughout the shift during the evening shift drills. All drills are conducted between 3:04 PM and 4:16 PM,

Based on observation, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:
On facility tour between 12:30 PM on 4/23/12 and 4:00 PM on 4/24/12, it was observed that the 2nd floor wall mounted, fold down writing desks and fold down computer work stations located near rooms 221 and 2200 did not retract as designed when tested.