HospitalInspections.org

Based on observation and interview, the facility failed to ensure egress was not equipped with a latch or lock that required a tool or key from the egress side. These deficiencies affect 4 of 4 main level smoke compartments.

Findings include:

1. During an observation on 2/22/17 at 11:15 a.m., the main entrance was tested with a wander guard device. The door locked.

In an interview on 2/22/17 at 11:15 a.m., staff member A said the wander guard system would lock the door. It would not unlock until staff entered the code in the keypad to the left of the door. All exits using the wander guard system included:
a.) main exit,
b.) the north exit,
c.) emergency room door, and
d.) the dock out of the kitchen.

Based on observation, the facility failed to maintain the two hour barrier due to not having sealed the opening around blue cables that ran through the wall in accordance with NFPA 101, 2012 Edition, Section 7.2.4.3.1. This deficiency affects 2 smoke compartments in the basement.

Findings include:

1. During an observation on 2/22/17 at 1:55 p.m., the two hour barrier above the suspended ceiling in the basement was observed. An opening existed around a set of blue communication cables that passed through the wall.

Based on observation, record review and interview, the facility failed to ensure the five year obstruction test was completed in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 2011 Edition, Section 14.2.1 and Section 5.2.1.1.1 to ensure sprinklers were positioned to ensure satisfactory performance with respect to activation time. These deficiencies can affect all smoke compartments in the facility.

Findings include:

1. Review of the 2/14/17 quarterly sprinkler inspection showed the piping system was last checked for "stoppage, corrosion or foreign material in 2011."

In an interview on 2/22/17 at 3:15 p.m., staff member A said he had called [the sprinkler inspection company] and they said the obstruction investigation was due this year.

The facility was told if documentation of the last obstruction investigation was found to fax it to the survey agency by 2/23/17. The facility sent no additional documentation regarding when the last obstruction investigation was completed.

During an observation on 2/22/17 at 1:49 p.m., there were seven openings in the suspended ceiling in the elevator mechanical room. The openings existed due to broken ceiling tile, conduits and cables that penetrated the ceiling. Unsealed holes in the ceiling can cause a delay in sprinkler response.

Based on observations and interview, the facility failed to ensure where power strips were used in resident rooms for non-patient-care-related electrical equipment met UL (Underwriter Laboratory) 1363 and where used with patient-care-related electrical equipment met UL 1363A or UL 60601-1. These deficiencies affect 2 of 4 main level smoke compartments.

Findings include:

1. During observations on 2/22/17 between 10:14 a.m. to 11:40 a.m., power strips were observed in resident rooms 3, 4, 5, 6, 7, 8, 9 and 11 in the long term care portion of the facility.

In an interview on 2/22/17 at 10:30 a.m., staff member A said we do not have the UL 1363s.

During an observation on 2/22/17 at 11:40 a.m., in observation room #4 on the hospital side IV (intravenous) pumps were plugged into a power strip.