HospitalInspections.org

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 1:59 PM on April 9, 2013, the exterior egress path from the Clinic east exit door (which serves as an egress path for the health care occupancy) was observed to not be complete to a public way as required by 7.7.1. because no stable walking surface to the public way is provided.

Based on random observation during the survey walk-through and staff interview, not all exterior egress paths are illuminated in such a manner that the failure of one fixture will not leave the area in darkness as prohibited by 19.2.8. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. At 1:27 PM on April 9, 2013, the exterior egress path from the east Hospital exit door was observed to not be provided with lighting, on emergency power, which is equipped so that the failure of 1 fixture (bulb) will not leave the area in darkness.

Based on staff interview, fire drills are not held in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the activation of the building fire alarm system may not alert emergency forces to the condition.

Findings include:

A. During an interview held in an Administrative Office 8:47 AM on April 10, 2013, the provider's Facilities Director confirmed that fire drills conducted during the Second (night) Shift) do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on staff interview, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. This deficiency could affect any patients, staff, or visitors in the building because the failure of the fire dampers could permit fire or smoke to pass through fire and smoke rated assemblies.

Findings include:

A. During an interview held in an Administrative Office 8:39 AM on April 10, 2013, the provider's Facilities Director confirmed that fire dampers are not tested every 4 years as required by NFPA 90A 1999 3-4.7.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99. This deficiency could affect any patients, staff, or visitors in the building because the life safety branch of the building's Type 1 Emergency Electrical System (EES) could become compromised.

Findings include:

A. At 1:34 PM on April 9, 2013, the duplex receptacle on emergency power located at the headwall in the Stage I Recovery Room was observed to be served from the life safety branch of the building's Type 1 EES, and not by the critical branch as required by NFPA 99 1999 3-4.2.2.2(c)(8)(a) and NFPA 70 1999 517-33(a)(8)(a).

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 1:59 PM on April 9, 2013, the exterior egress path from the Clinic east exit door (which serves as an egress path for the health care occupancy) was observed to not be complete to a public way as required by 7.7.1. because no stable walking surface to the public way is provided.

Based on random observation during the survey walk-through and staff interview, not all exterior egress paths are illuminated in such a manner that the failure of one fixture will not leave the area in darkness as prohibited by 19.2.8. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. At 1:27 PM on April 9, 2013, the exterior egress path from the east Hospital exit door was observed to not be provided with lighting, on emergency power, which is equipped so that the failure of 1 fixture (bulb) will not leave the area in darkness.

Based on staff interview, fire drills are not held in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the activation of the building fire alarm system may not alert emergency forces to the condition.

Findings include:

A. During an interview held in an Administrative Office 8:47 AM on April 10, 2013, the provider's Facilities Director confirmed that fire drills conducted during the Second (night) Shift) do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on staff interview, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. This deficiency could affect any patients, staff, or visitors in the building because the failure of the fire dampers could permit fire or smoke to pass through fire and smoke rated assemblies.

Findings include:

A. During an interview held in an Administrative Office 8:39 AM on April 10, 2013, the provider's Facilities Director confirmed that fire dampers are not tested every 4 years as required by NFPA 90A 1999 3-4.7.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99. This deficiency could affect any patients, staff, or visitors in the building because the life safety branch of the building's Type 1 Emergency Electrical System (EES) could become compromised.

Findings include:

A. At 1:34 PM on April 9, 2013, the duplex receptacle on emergency power located at the headwall in the Stage I Recovery Room was observed to be served from the life safety branch of the building's Type 1 EES, and not by the critical branch as required by NFPA 99 1999 3-4.2.2.2(c)(8)(a) and NFPA 70 1999 517-33(a)(8)(a).