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.

Findings include:

A. At 9:26 AM on August 10, 2011, the travel distance from the most remote point of the (Third Floor level) Mechanical Penthouse (as measured to the door to the Second Floor door to the North Exit Stair because the Stair serving the Penthouse discharges interior to the building on the Second Floor) was observed to be in excess of 100 feet as prohibited by Subpart (c) of Exception 1. to 7.12.1. This deficiency could affect any staff working in the Mechanical Penthouse because the excessive travel distance could prevent that staff from reaching an exit under fire conditions.

Update 05/24/12: Based upon observation the designated exit for the Penthouse is a new metal caged ladder, and it discharges into an enclosed fence containing a padlocked gate. The door does not opened readily from the egress side to comply with 7.2.1.5.1.

B. 1. Corrected 01/19/2012.

2. Corrected 01/19/2012.

C. Corrected 01/19/2012.

Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During an interview held in the First Floor Conference Room at 8:40 AM on August 10, 2011, the provider's Director of Maintenance was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. This deficiency could affect all patients and staff in the building because the lack of knowledge about such life safety components could result in the failure to protect the components properly. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Occupancy classifications.

2. Portions of the building covered by an automatic sprinkler system.

3. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, and ventilation shafts.

5. Smoke barrier walls and areas (in square feet) of smoke compartments.

6. Exit access corridors and designated corridor walls.

7. The limits and areas (in square feet) of all suites.

8. Hazardous areas and their fire resistance ratings.

9. Exits.

10. Other special fire protection features such as areas of the building covered by a smoke evacuation system.

Update 01/19/2012: The construction documents for the facility were not available for review during this follow-up survey and the facility did not meet the completion date of 8/22/2011 noted on their Plan of Correction.

Update 05/24/12: The facility's Life Safety drawings were not readily available during this survey and we were not able to confirm and verify designated fire/smoke compartments to clear this tag.

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.

Update 05/24/12: Most but not all of the deficiencies that require interim measures have been corrected. Interim measures are required for remaining deficiencies and must be enhanced as needed, until all items are corrected.

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 ay patients being housed or treated in the cited locations, because electrical power may not be available for necessary equipment under all circumstances.

Findings include:

A. 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 in a Second Floor Patient Sleeping Room at 9:54 AM on August 10, 2011, the provider's Director of Maintenance confirmed that this condition exists at all 25 general patient care beds in the facility.

B. At 11:25 AM on August 10, 2011, the 4 First Floor Emergency Department Exam Rooms were observed lack at least 1 duplex receptacle which is served by the building emergency electrical system as required by NFPA 70 1999 517-18(a).

C. Corrected 01/19/12.

Update 05/24/12: According to the CEO this tag will be addressed during the first phase of construction of March through October 2013.