HospitalInspections.org

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. At 11:19 AM, a pair of transfer grilles were observed, in the Corridor wall of Data Input Room D31, as prohibited by 19.3.6.4. This deficiency could affect any patients, visitors, or staff in the D Wing Outpatient Clinic by permitting smoke to pass from the Data Input Room into the adjacent Corridor.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the rooms to the adjacent Corridor.

Findings include:

A. At 11:17 AM, the door to Housekeeping Room D32A was observed to not be positive latching as required by 19.3.6.3.2.

B. At 12:22 PM, the inactive leaf at the pair of doors to the C Wing Staff Work Room was observed to be provided with a slide bolt at the floor and no other latching mechanism. The slide bolt does not constitute a positive latching device required for this leaf by 19.3.6.3.2.

C. At 12:47 PM, the door to MIS Office B273 was observed to be equipped with a deadbolt with a thumbturn retractor. When extended, the deadbolt prevents the door from being positive latching as required by 19.3.6.3.2. Also see K-038 regarding the number of operations required to pass through this door.

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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 attempting to use these egress by impeding their progress.

Findings include:

A. Doors were observed at which the floor level is lower on one side than the other by more than 1/2", as prohibited by 7.2.1.3., because the exterior concrete is lower than the building flor line. Locations observed include:
1. 12:18 PM: Exterior exit door across from Room C 317.

2. 2:29 PM: Exterior exit door across from Room B215.

B. At 11:16 AM, the door to Telephone Closet D32 was observed to obstruct the adjacent cross-corridor door, when in the fully open (180 degree) position, in a manner prohibited by 7.2.1.4.4.

C. At 12:47 PM, the door to MIS Office B273 was observed to be equipped with a deadbolt with a thumbturn retractor. The door thus requires two operations to gain egress as prohibited by 7.2.1.5.4. Also refer to K-018 regarding the positive latching of this door.

D. At 12:32 PM, the following conditions were observed at the door to the Courtyard between the B and C Wings (located across from the Dietary Department):
1. The door was observed to not be a side-hinged, pivoting door as required by 7.2.1.4.1.

2. The door was equipped with a locking device which would permit the door to be secured against egress from the Courtyard as prohibited by 7.2.1.5.1.

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Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. At 1:55 PM and based on document review, fire drills were determined to not be conducted under varying conditions i.e., at varying times as required by 19.7.1.2. This deficiency could affect all patients, staff, and visitors in the building because staff may not be properly trained to react under fire conditions. During the calendar years 2011 and 2012, fire drill records indicated that the following First Shift fire drills were all conducted within an hour of each other:

1. February 4, 2011: 13:29.

2. April 29, 2011: 14:00.

3. July 26, 2011: 13:35.

4. October 24, 2011: 13:13.

5. January 29, 2012: 13:59.

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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Exit doors from building stories or fire compartments were observed that lack fire alarm pull manual stations within 5'-0" of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2. These deficiencies could affect all patients, staff, and visitors in the building because the lack of manual fire alarm pull stations could delay them from being aware of fire conditions. Locations observed include:

1. 11:24 AM: North exterior door from the D Wing.

2. 2:29 PM: Exterior door across from Room B215.

B. At 1:36 PM, the pair of doors at the 2 hour separation between the hospital and the F Wing was observed to lack smoke detectors within 5'-0" of either side as required by NFPA 72 1999 2-10.6.5.1. This deficiency could affect any patients, visitors, or staff in the immediate area because the failure of the doors under fire conditions could permit fire and smoke to pass into the hospital.

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Based on random observation during the survey walk-through, the building's emergency generator is not installed and maintained in accordance with NFPA 99.

Findings include:

A. The starter batteries for the emergency generators (2 thus) were observed to lack an automatically controlled heater required by NFPA 110 1999 3-3.1. These deficiencies could affectall patients, staff, and visitors in the building because the generators could fail to start under emergency conditions.

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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.

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Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the areas listed because electrical power may not be available for their treatment.

Findings include:

A. At 12:08 PM, general care patient beds were observed at which 1 circuit is not from the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held at that time and in a Patient Sleeping Room, the provider's Director of Plant Operations confirmed that this condition exists at each Patient Sleeping Room bed location.

B. At 1:10 PM, the 2 identified Stage I Recovery Bays (which constitute critical care patient beds) were observed to not be provided with a minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

A. At 11:19 AM, a pair of transfer grilles were observed, in the Corridor wall of Data Input Room D31, as prohibited by 19.3.6.4. This deficiency could affect any patients, visitors, or staff in the D Wing Outpatient Clinic by permitting smoke to pass from the Data Input Room into the adjacent Corridor.

.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the rooms to the adjacent Corridor.

Findings include:

A. At 11:17 AM, the door to Housekeeping Room D32A was observed to not be positive latching as required by 19.3.6.3.2.

B. At 12:22 PM, the inactive leaf at the pair of doors to the C Wing Staff Work Room was observed to be provided with a slide bolt at the floor and no other latching mechanism. The slide bolt does not constitute a positive latching device required for this leaf by 19.3.6.3.2.

C. At 12:47 PM, the door to MIS Office B273 was observed to be equipped with a deadbolt with a thumbturn retractor. When extended, the deadbolt prevents the door from being positive latching as required by 19.3.6.3.2. Also see K-038 regarding the number of operations required to pass through this door.

.

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 attempting to use these egress by impeding their progress.

Findings include:

A. Doors were observed at which the floor level is lower on one side than the other by more than 1/2", as prohibited by 7.2.1.3., because the exterior concrete is lower than the building flor line. Locations observed include:
1. 12:18 PM: Exterior exit door across from Room C 317.

2. 2:29 PM: Exterior exit door across from Room B215.

B. At 11:16 AM, the door to Telephone Closet D32 was observed to obstruct the adjacent cross-corridor door, when in the fully open (180 degree) position, in a manner prohibited by 7.2.1.4.4.

C. At 12:47 PM, the door to MIS Office B273 was observed to be equipped with a deadbolt with a thumbturn retractor. The door thus requires two operations to gain egress as prohibited by 7.2.1.5.4. Also refer to K-018 regarding the positive latching of this door.

D. At 12:32 PM, the following conditions were observed at the door to the Courtyard between the B and C Wings (located across from the Dietary Department):
1. The door was observed to not be a side-hinged, pivoting door as required by 7.2.1.4.1.

2. The door was equipped with a locking device which would permit the door to be secured against egress from the Courtyard as prohibited by 7.2.1.5.1.

.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. At 1:55 PM and based on document review, fire drills were determined to not be conducted under varying conditions i.e., at varying times as required by 19.7.1.2. This deficiency could affect all patients, staff, and visitors in the building because staff may not be properly trained to react under fire conditions. During the calendar years 2011 and 2012, fire drill records indicated that the following First Shift fire drills were all conducted within an hour of each other:

1. February 4, 2011: 13:29.

2. April 29, 2011: 14:00.

3. July 26, 2011: 13:35.

4. October 24, 2011: 13:13.

5. January 29, 2012: 13:59.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Exit doors from building stories or fire compartments were observed that lack fire alarm pull manual stations within 5'-0" of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2. These deficiencies could affect all patients, staff, and visitors in the building because the lack of manual fire alarm pull stations could delay them from being aware of fire conditions. Locations observed include:

1. 11:24 AM: North exterior door from the D Wing.

2. 2:29 PM: Exterior door across from Room B215.

B. At 1:36 PM, the pair of doors at the 2 hour separation between the hospital and the F Wing was observed to lack smoke detectors within 5'-0" of either side as required by NFPA 72 1999 2-10.6.5.1. This deficiency could affect any patients, visitors, or staff in the immediate area because the failure of the doors under fire conditions could permit fire and smoke to pass into the hospital.

.

Based on random observation during the survey walk-through, the building's emergency generator is not installed and maintained in accordance with NFPA 99.

Findings include:

A. The starter batteries for the emergency generators (2 thus) were observed to lack an automatically controlled heater required by NFPA 110 1999 3-3.1. These deficiencies could affectall patients, staff, and visitors in the building because the generators could fail to start under emergency conditions.

.

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 and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the areas listed because electrical power may not be available for their treatment.

Findings include:

A. At 12:08 PM, general care patient beds were observed at which 1 circuit is not from the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held at that time and in a Patient Sleeping Room, the provider's Director of Plant Operations confirmed that this condition exists at each Patient Sleeping Room bed location.

B. At 1:10 PM, the 2 identified Stage I Recovery Bays (which constitute critical care patient beds) were observed to not be provided with a minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

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