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Based on observation and staff interview, not all exit access doors are available at all times for egress. This deficiency could affect all patients, staff and visitors present, by compromising the direction of egress during an emergency situation.

Findings include:

A. On 11/27/2018 at 11:50am while accompanied by the SM, doors to exit stairs were observed to be locked against egress with several locking devices located on the wall adjacent to the latch side of the door. During discussion, it was stated that one keyed lock was for the fire alarm, similar to a pull station, the other keyed lock was a lock for the exit stair door. It is unclear if these locking mechanisms coordinate during a fire emergency. This condition does not comply with 19.2.2.2.6 (2).

B. On 11/27/2018 at 11:59am while accompanied by the SM, doors to exit stairs are locked against egress. The surveyor requested three different hospital staff members assigned to the Behavioral Unit to unlock an exit stair door. Two of the three staff members did not carry a key, therefore this condition does not comply with 19.2.2.2.6 (1),(2) and (3).

Based on an observation, not all fire barrier doors are being maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from one portion of the building to another.

The finding is:

On 11/27/18 at 12:50pm while accompanied by HVAC-M, it was determined that in the Basement A-Wing, 2HR fire doors FD-09, contained one door leaf that did not latch to the door frame when tested. This does not comply with Section 19.2.2.2.8.

Based on observation, not all exit discharges have a hard packed all-weather travel surface leading to a public way. This could affect all occupants needing to exit the building, particularly in an emergency situation.

Findings include:

On 11/27/2018 at 10:30am while accompanied by the SM, exit discharges were observed which do not provide a maintained means of egress. This condition does not comply with the Sections 19.2.7, 7.7, 7.1.6.4 and 7.1.10.1 including CMS Memo S&C 05-38.

Locations include:

1. Hospital East Wing, N/S corridor adjacent to conference rooms leads to the exterior, the pair of discharge doors did not completely open due to the frozen condition of the right leaf.

2. Hospital East Wing exterior discharge path, the sidewalk was covered in ice and snow, no usable path provided.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building during an emergency situation.

The finding is:

On 11/27/2018 at 2:10pm while accompanied by the SM, only one path of exit access is identified by exit signage which does not comply with 19.2.5.4. Location observed: 4th floor, Nursery suite

Based on an observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire event.

Findings include:

On 11/27/18 at 2:05pm while accompanied by HVAC-M, it was determined that on the Ground Floor, PACU, Soiled Utility Room 1672 door would not latch to the frame due to a staff member placing paper material in the latch plate and taping over it. This prevented the door from properly latching to the frame to secure the hazardous area. This does not comply with Section 19.3.2.

Based on observation the facility failed to correctly install kitchen ventilation and protection equipment. This deficient practice could result in the uncontrolled spread of fire and products of combustion during kitchen cooking operations, which may affect patients, staff and visitors.

Findings include:

A. On 11/27/2018 at 1:30pm while accompanied by the POMM, in the Ground Floor Kitchen, the grease hood filter segments were separated allowing grease laden vapor to bypass the filters. (Section 19.3.2.5 / NFPA 96, 2008, 6.2.3.3)

B. On 11/27/2018 at 1:35pm while accompanied by the POMM, in the Ground Floor Kitchen, the fire protection nozzles are not provide with blowoff caps to limit the amount of grease buildup. (NFPA 17A, 2009, 7.2)

Based on observation the facility failed to provide protection for the fire alarm components. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 11/27/2018 at 1:41pm while accompanied by the POMM, in the Ground Floor Storage Room 1007, the fire alarm Notification Appliance Circuit (NAC) panel located in this room was not provided with automatic smoke detection as required by Section 19.3.4.1 & 9.6.1.8, NFPA 72 2010, 10.5.


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B. On 11/27/18 at 1:57pm while accompanied by HVAC-M, it was determined that on the Ground Floor, Equipment Storage Room 1615 contained a fire alarm control panel. This room was not installed with smoke detection. This does not comply with Section 19.3.4.1. and 9.6.1.8, NFPA 72 2010, 10.5.

Based on an observation, the fire alarm detection system was not constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if the fire alarm control panel did not operate properly during a fire event.

The finding is:

On 11/28/18 at 10:05 am while accompanied by the SM, it was determined that a large closet contained a fire alarm Notification Appliance Circuit (NAC) panel. This closet was not provided with automatic smoke detection to comply with 39.3.4 & 9.6.1.8.1, NFPA 72 2010, 10.5 Location observed: Second floor, Infusion Center, Storage closet located in the Staff Break room.

Based on document review, the facility failed to correctly test components for the elevator firefighter service and recall systems. Failure to maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 11/28/2018 at 9:05am, while accompanied by the POMM and SM , documentation for the monthly testing of fire fighter recall does not provide a test of the emergency operation regarding Phase II, (one floor operation utilizing smoke detection) to comply with ASME A17.3, 2008, ASME A17.1, 8.6.11.1

Based on document review and staff interviews, the facility failed to provide compliant smoke management systems. This deficient practice could result in the uncontrolled spread of products of combustion during a fire event, which may affect patients, staff and visitors.

Findings include:

On 11/28/2018 at 9:15am while in the company of the POMM, documentation was not be provided to demonstrate semiannual testing of the facilities smoke control systems (NFPA 92, 2012, 8.6) for the following:

1 Atrium smoke exhaust system

2. Stairwell pressurization systems

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 11/27/2018 at 1:15pm while accompanied by the SM, it was determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70 2011 517-19(A).
The location observed: C-Section procedure rooms