HospitalInspections.org

The CONDITION of Physical Environment is NOT MET.
Based on the Life Safety Code survey conducted 02/14/11 thru 02/16/11 the Condition of Physical Environment, Safety from Fire is NOT MET. This would affect all patients and staff.

Findings include:

Please see findings under the Life Safety Code Survey as follows:

K 21, addressed the facility failure to ensure that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure was held open only by devices arranged to automatically close all such doors.
K 25, addressed the facility failure to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.
K 29, addressed the facility failure to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors.
K 38, addressed the facility failure to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1.
K 43 addressed the facility failure to ensure that where special door locking arrangements were permitted in mental health facilities, the use of the locks on patient sleeping rooms were utilized when the clinical needs of the patients required specialized security measures for their safety.
K 76, which addressed the facility failure to ensure that medical gas storage were protected in accordance with National Fire Protection Association (NFPA)99, Standards for Health Care Facilities. NFPA 99 requirements for storage requirements (location, construction, arrangement) are addressed at 4-3.1.1.2.
K 130, addressed the facility failure to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1.
And a second example addresses the facility's failure to ensure the requirement in National Fire Protection Association (NFPA) 90-A. Standard for the Installation of Air-Conditioning and Ventilation Systems, 1999, Chapter 3, Integration of a ventilation and air conditioning system(s) with building construction , 3-4.7, fire and smoke dampers, with regards to verification that dampers were checked, that they fully closed; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

CB
Based on observation and interview, the facility failed to ensure patient rooms 2611, 2613, and 2618 were maintained in such a manner conducive to the well being of the patients in those rooms and failed to ensure the contents of the refrigerator on the recovery unit was free of expired food items. Rooms 2611, 2613, and 2618 contained six patients in all, and the recovery unit had a census of 28 patients. The facility had a total census of 133 patients.

Findings:

In the afternoon of 01/14/11 the surveyor and Staff J toured the 2600 unit-a unit designed to treat adolescent patients. During the tour, the surveyor and Staff J observed several examples of offensive graffiti.. The surveyor observed "money over bitches money 's over here" written on the ceiling above the desk for the patient in the "A" bed in room 2618. The surveyor observed written on the wall just to the left of the actual "A" bed: "Fuck" and "Bitch".
The surveyor observed in room 2611 written on the inside of the entry door: "DJA cum".
The surveyor observed in room 2613 written on the door to the bathroom: "They are coming for you" and "I (the heart symbol) penis."
The surveyor observed that a 14-year-old and a 15-year-old girl were assigned to room 2618. The surveyor observed that a 15 and 16-year-old girl were assigned to room 2611. The surveyor observed that a 14 and 15-year-old girl were assigned to room 2613.
During the tour of 01/14/11 Staff J confirmed the observations. During the interview, he/she stated housekeeping comes through the unit at least once a day to clean the rooms.
On 02/15/11 the surveyor and Staff J again toured the 2600 unit at 4:15 P.M. The surveyor and Staff J observed the same graffiti in rooms 2611, 2613, and 2618. In an interview during the tour, Staff J said housekeeping had been through to clean the rooms. The surveyor observed that Staff J was able to wipe off "DJA cum" from the door and "Fuck" and "bitch" from the wall using a paper towel soaked with only water.

During the tour, the surveyor asked Staff J why housekeeping hadn't wiped off the graffiti. He/she said he/she has asked them, many times, to do so when they clean the rooms. He/she said patients are not given and are not allowed to have any pencil or permanent ink pens. He/she said they are allowed to have only dry erase markers or crayons.

On 02/16/11 at 10:45 A.M. the surveyor toured with Staff O the recovery unit. The surveyor observed in the patient's refrigerator on the unit three half-pint containers of two percent milk with an expiration date of 02/14/11, a half-pint of skim milk with an expired date of 02/12/11, a one once packet of imitation sour cream dated 11/03/10, and another dated 11/15/10.

Staff O confirmed the observations.

Based on the review of documentation presented by the facility, interview of facility staff and observations made during the Life Safety Code tour, the facility failed to ensure that it met all of the requirements for Life Safety from Fire.

Findings include:

Please see the Life Safety Code survey under the following areas:
K - 21 addressed the facility's failure to ensure that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure was held open only by devices arranged to automatically close all such doors.

K 25 - addressed the facility's failure to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

K 29 - addressed the facility's failure to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors.
K 38 - addressed the facility's failure to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1.

K 43 - addressed the facility's failure to ensure that where special door locking arrangements were permitted in mental health facilities, the use of the locks on patient sleeping rooms were utilized when the clinical needs of the patients required specialized security measures for their safety.

K 76 - which addressed the facility's failure to ensure that medical gas storage were protected in accordance with National Fire Protection Association (NFPA)99, Standards for Health Care Facilities. NFPA 99 requirements for storage requirements (location, construction, arrangement) are addressed at 4-3.1.1.2.

K 130 - addressed the facility's failure to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1.
And a second example addressing the facility's failure to ensure the requirement located in National Fire Protection Association (NFPA) 90-A. Standard for the Installation of Air-Conditioning and Ventilation Systems, 1999, Chapter 3, Integration of a ventilation and air conditioning system(s) with building construction , 3-4.7, fire and smoke dampers, with regards to verification that dampers were checked, that they fully closed; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.