HospitalInspections.org

Based on visual observation the facility failed to provide exits that are marked by approved, readily visible signs in areas on 3 of six floors. This deficiency if not corrected could have the potential to affect 126 patients.

Findings: During tour of building on 12-22-2011 and 12-26-2011 the following areas did not have exit signs where the way to reach a exit door was not readily apparent to occupants.
1. 4 South A hall outside of mechanical room
2. In front of car 2 nurses station
3. Entering 4 South A hall by data and electrical room
4. 4 North A hall stairwell door
5. 2nd floor by ER ambulance room above cross corridor doors
6. 2nd floor in corridor going to Mary Bird Perkins, near surgery rear exit door.
7. No. A hall by room 2213 at stairwell door
8. 1st floor above exit door going to Mary Bird Perkins parking lot.

Based on visual observation the facility failed to provide a fire rated room to store combustibles in 1 of 2 smoke barriers on the 3rd floor. This deficiency if not corrected could have the potential to cause harm to 36 patients in the facility.

Findings: During tour of facility on 12-22-2011 between 8:30 a.m. 3:00 p.m. the PEDS playroom was observed storing several television sets and a large number of cardboard boxes. The playroom does not have fire rated walls or a 45 minute rated fire door.

Based on visual observation the facility failed to provide a key override at 1 of 4 doors with special locking capabilities. This deficiency if not corrected could have the potential to cause harm to 45 patients if not corrected.

Findings: During tour of building on 12-27-2011 at 11:00 a.m. the entrance doors to A hall PEDS were observed not having a key override for the magnetic locking device.

Based on visual observation the facility failed to provide a key override for a magnetically locked rear exit door in the emergency room. This deficiency if not corrected could have the potential to cause harm to 14 patients if not corrected.

Findings: During tour of the building on 12-28-2011 between 8:30 a.m. and 3:30 p.m. the emergency room rear exit door equipped with a magnetic lock at the corridor to Mary Bird Perkins was observed not having a key override. Also, the doors on the 3rd floor leaving PICU corridor to elevators has delayed egress magnets installed on them, however there is no sign reading:
* On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on visual observation the facility failed to provide privacy curtains that do not obstruct the sprinkler system water pattern in all of the patient rooms on the 6th floor. This deficiency if not corrected could have the potential to cause harm to 20 patients if not corrected.

Findings: During tour of building on 12-22-2011 between 8:30 a.m. and 3:00 p.m. the privacy curtains in each of the resident rooms on the 6th floor was observed not having one half inch mesh sewn at the top of the curtain, as not to obstruct the water flow from the sprinkler system in case of a fire.

Based on visual observation the facility failed to provide sprinkler protection in areas of 2 of 6 floors of the building. This deficiency if not corrected could have the potential to cause harm to 70 patients if not corrected.

Findings: During tour of building on 12-22-2011 and 12-28-2011 between the hours of 8:30 a.m. and 3:00 p.m. the following areas were observed not being protected by the sprinkler system.
1. 4th floor North car nurses station staff lounge and restroom.
2. 4th floor North car 3 staff lounge restroom.
3. 1st floor 2 restrooms by central supply.

Based on visual observation the facility failed to provide a exit discharge to the public way that is accessible at all times. This deficiency if not corrected could have the potential to cause harm to 24 patients.

Findings: During tour of building on 12-28-2011 between 8:30 a.m. and 3:30 p.m. the exit discharge from 1 North A hall was observed not being constructed of a hard and reliable substance from the chapel to the public way.
7.5.1.1
Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.
7.5.1.2*

Based on visual observation the facility failed to provide exits that are marked by approved, readily visible signs in areas on 3 of six floors. This deficiency if not corrected could have the potential to affect 126 patients.

Findings: During tour of building on 12-22-2011 and 12-26-2011 the following areas did not have exit signs where the way to reach a exit door was not readily apparent to occupants.
1. 4 South A hall outside of mechanical room
2. In front of car 2 nurses station
3. Entering 4 South A hall by data and electrical room
4. 4 North A hall stairwell door
5. 2nd floor by ER ambulance room above cross corridor doors
6. 2nd floor in corridor going to Mary Bird Perkins, near surgery rear exit door.
7. No. A hall by room 2213 at stairwell door
8. 1st floor above exit door going to Mary Bird Perkins parking lot.

Based on visual observation the facility failed to provide a fire rated room to store combustibles in 1 of 2 smoke barriers on the 3rd floor. This deficiency if not corrected could have the potential to cause harm to 36 patients in the facility.

Findings: During tour of facility on 12-22-2011 between 8:30 a.m. 3:00 p.m. the PEDS playroom was observed storing several television sets and a large number of cardboard boxes. The playroom does not have fire rated walls or a 45 minute rated fire door.

Based on visual observation the facility failed to provide a key override at 1 of 4 doors with special locking capabilities. This deficiency if not corrected could have the potential to cause harm to 45 patients if not corrected.

Findings: During tour of building on 12-27-2011 at 11:00 a.m. the entrance doors to A hall PEDS were observed not having a key override for the magnetic locking device.

Based on visual observation the facility failed to provide a key override for a magnetically locked rear exit door in the emergency room. This deficiency if not corrected could have the potential to cause harm to 14 patients if not corrected.

Findings: During tour of the building on 12-28-2011 between 8:30 a.m. and 3:30 p.m. the emergency room rear exit door equipped with a magnetic lock at the corridor to Mary Bird Perkins was observed not having a key override. Also, the doors on the 3rd floor leaving PICU corridor to elevators has delayed egress magnets installed on them, however there is no sign reading:
* On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on visual observation the facility failed to provide privacy curtains that do not obstruct the sprinkler system water pattern in all of the patient rooms on the 6th floor. This deficiency if not corrected could have the potential to cause harm to 20 patients if not corrected.

Findings: During tour of building on 12-22-2011 between 8:30 a.m. and 3:00 p.m. the privacy curtains in each of the resident rooms on the 6th floor was observed not having one half inch mesh sewn at the top of the curtain, as not to obstruct the water flow from the sprinkler system in case of a fire.

Based on visual observation the facility failed to provide sprinkler protection in areas of 2 of 6 floors of the building. This deficiency if not corrected could have the potential to cause harm to 70 patients if not corrected.

Findings: During tour of building on 12-22-2011 and 12-28-2011 between the hours of 8:30 a.m. and 3:00 p.m. the following areas were observed not being protected by the sprinkler system.
1. 4th floor North car nurses station staff lounge and restroom.
2. 4th floor North car 3 staff lounge restroom.
3. 1st floor 2 restrooms by central supply.

Based on visual observation the facility failed to provide a exit discharge to the public way that is accessible at all times. This deficiency if not corrected could have the potential to cause harm to 24 patients.

Findings: During tour of building on 12-28-2011 between 8:30 a.m. and 3:30 p.m. the exit discharge from 1 North A hall was observed not being constructed of a hard and reliable substance from the chapel to the public way.
7.5.1.1
Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.
7.5.1.2*