HospitalInspections.org

Based on observation and staff interview, the facility did not provide exit access doors into to the corridor that would resistant the passage of smoke as NFPA 101 18.3.6.3.1 as evidenced by the following item. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:21pm that the paired doors from the ED suite into the corridor system were not equipped with an astragal to insure this corridor opening was smoke tight. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Based on observation and staff interview, the facility did not provide doors at the opening of the one-hour smoke compartment wall that would resistant the passage of smoke as required in NFPA 101 18.3.5.7 and evidenced by the following item. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:06pm that the paired doors within the smoke compartment wall located near Ultrasound were not equipped with an astragal to prevent the passage of smoke through this opening within the smoke comparment. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide an exit door that was capable of being opened with a maximum force of 30 ft/lb as evidenced by the following item. This does not comply with NFPA 101-Section 18.2.1 and chapter 7-Section 7.2.1.4.5. This deficient practice could have an effect on all occupants of the facility that needed to use this door to exit the building.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:45pm that the exit door located at the west end of Corridor #1509 took more than 30 ft/lbs of force to open the door. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide an exit access corridor that was a minimum of 8'-0" clear and unobstructed in width as required in NFPA 101-Section 18-2.3.3 as evidenced by the following item. This deficient practice could have an all occupants that would use this corridor in a fire situation.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:45pm that two couches, plants and a stand were located within the 8'-0" clear space required for egress width through the Waiting area. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide a fire alarm system that was compliant to NFPA 72 as evidenced by the following item. This deficient practice could affect the five occupants using this space.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 2:09pm that no visible appliance was installed within Records #1065, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide a fire alarm system that was compliant to NFPA 72 as evidenced by the following item. This deficient practice could affect the two occupants using this space.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 10:11am that no visible appliance was installed within Office #1157, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #2: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 10:13am that no visible appliance was installed within Office #1151, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #3: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 10:14am that no visible appliance was installed within Office #1147, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and interview, the facility did not provide a sprinkler system that complied with the minimum requirements of NFPA 13 (1999 edition). This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: On 09/17/12 at 10:39am Surveyor 14108 observed the that the sprinkler head located above the audiology booth was closer than 18" below the sprinkler deflector. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #1a: On 09/17/12 at 10:39am Surveyor 14108 observed the that no sprinkler head was located in the audiology booth. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #2: On 09/17/12 at 11:00am Surveyor 14108 observed the storage cabinets located within Appointments #1007 were closer than 18" below the sprinkler deflector. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Based on observation and interview, the facility did not provide a sprinkler system that complied with the minimum requirements of NFPA 13 (1999 edition). This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: On 09/17/12 at 1:48 pm Surveyor 14108 observed the storage cabinets located within Storage #1058 were closer than 18" below the sprinkler deflector. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #2: On 09/17/12 at 12:40 pm Surveyor 14108 observed the a television was located closer than 18" below the sprinkler deflector in Patient room #1526. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #3: On 09/17/12 at 1:13 pm Surveyor 14108 observed the sprinkler located within Control room #1405 was not equipped with an escutcheon. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Based on observation and staff interview, the facility did not provide a dedicated space for generator as required by NFPA 110 (1999 Ed) and evidenced by the following item. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 11:31am that combustible items were being kept within the room dedicated to the generator. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide an electrical system that met the requirements of NFPA 70 (1999 Ed) as evidenced by the following items. This deficient practice could have an all occupants who were to use the outlets within these spaces.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 11:11am that no GFCI protection device was installed at the outlet above the counter in the Physical Therapy work area that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #2: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 11:41am that no GFCI protection device was installed at the outlet above the counter in Dining #1041 that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #3: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:53pm that no GFCI protection device was installed at two outlets above the counter in Soiled Utility #1548 that were located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #4: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:57pm that no GFCI protection device was installed at two outlets above the counter in the Meds room #1532 that were located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #5: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:01pm that no GFCI protection device was installed at the outlet above the counter in the Clean room #1538 that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #6: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:55pm that no GFCI protection device was installed at the outlet above the counter in the Cardiopulmonary #1028 that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide exit access doors into to the corridor that would resistant the passage of smoke as NFPA 101 18.3.6.3.1 as evidenced by the following item. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:21pm that the paired doors from the ED suite into the corridor system were not equipped with an astragal to insure this corridor opening was smoke tight. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Based on observation and staff interview, the facility did not provide doors at the opening of the one-hour smoke compartment wall that would resistant the passage of smoke as required in NFPA 101 18.3.5.7 and evidenced by the following item. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:06pm that the paired doors within the smoke compartment wall located near Ultrasound were not equipped with an astragal to prevent the passage of smoke through this opening within the smoke comparment. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide an exit door that was capable of being opened with a maximum force of 30 ft/lb as evidenced by the following item. This does not comply with NFPA 101-Section 18.2.1 and chapter 7-Section 7.2.1.4.5. This deficient practice could have an effect on all occupants of the facility that needed to use this door to exit the building.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:45pm that the exit door located at the west end of Corridor #1509 took more than 30 ft/lbs of force to open the door. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide an exit access corridor that was a minimum of 8'-0" clear and unobstructed in width as required in NFPA 101-Section 18-2.3.3 as evidenced by the following item. This deficient practice could have an all occupants that would use this corridor in a fire situation.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:45pm that two couches, plants and a stand were located within the 8'-0" clear space required for egress width through the Waiting area. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide a fire alarm system that was compliant to NFPA 72 as evidenced by the following item. This deficient practice could affect the five occupants using this space.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 2:09pm that no visible appliance was installed within Records #1065, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide a fire alarm system that was compliant to NFPA 72 as evidenced by the following item. This deficient practice could affect the two occupants using this space.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 10:11am that no visible appliance was installed within Office #1157, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #2: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 10:13am that no visible appliance was installed within Office #1151, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #3: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 10:14am that no visible appliance was installed within Office #1147, which is a common area as defined by NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and interview, the facility did not provide a sprinkler system that complied with the minimum requirements of NFPA 13 (1999 edition). This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: On 09/17/12 at 10:39am Surveyor 14108 observed the that the sprinkler head located above the audiology booth was closer than 18" below the sprinkler deflector. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #1a: On 09/17/12 at 10:39am Surveyor 14108 observed the that no sprinkler head was located in the audiology booth. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #2: On 09/17/12 at 11:00am Surveyor 14108 observed the storage cabinets located within Appointments #1007 were closer than 18" below the sprinkler deflector. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Based on observation and interview, the facility did not provide a sprinkler system that complied with the minimum requirements of NFPA 13 (1999 edition). This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: On 09/17/12 at 1:48 pm Surveyor 14108 observed the storage cabinets located within Storage #1058 were closer than 18" below the sprinkler deflector. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #2: On 09/17/12 at 12:40 pm Surveyor 14108 observed the a television was located closer than 18" below the sprinkler deflector in Patient room #1526. This had the potential to prevent full development of the sprinkler discharge pattern. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Item #3: On 09/17/12 at 1:13 pm Surveyor 14108 observed the sprinkler located within Control room #1405 was not equipped with an escutcheon. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff involved with this survey.

Based on observation and staff interview, the facility did not provide a dedicated space for generator as required by NFPA 110 (1999 Ed) and evidenced by the following item. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 11:31am that combustible items were being kept within the room dedicated to the generator. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Based on observation and staff interview, the facility did not provide an electrical system that met the requirements of NFPA 70 (1999 Ed) as evidenced by the following items. This deficient practice could have an all occupants who were to use the outlets within these spaces.

Findings include:
Item #1: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 11:11am that no GFCI protection device was installed at the outlet above the counter in the Physical Therapy work area that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #2: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 11:41am that no GFCI protection device was installed at the outlet above the counter in Dining #1041 that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #3: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:53pm that no GFCI protection device was installed at two outlets above the counter in Soiled Utility #1548 that were located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #4: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 12:57pm that no GFCI protection device was installed at two outlets above the counter in the Meds room #1532 that were located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #5: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:01pm that no GFCI protection device was installed at the outlet above the counter in the Clean room #1538 that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.

Item #6: While on a tour with Staff B and C on 09/17/12, Surveyor 14105 observed at 1:55pm that no GFCI protection device was installed at the outlet above the counter in the Cardiopulmonary #1028 that was located closer than 6' to the side of the sink. The condition was confirmed at the time of discovery by a concurrent observation and interview with the staff who were involved with this survey.