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Based on a direct observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect patients, staff and visitors if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include: On 1/27/2015 at 8:45 AM, while accompanied by E-1 and E-2 an observation on the first floor determined that the designated 2-hour fire double doors between the existing medical office building and the hospital building were deficient. The set of double doors contained one latch point located +/-36-inches above the floor at the exit device. No latching points were identified into the door frame or floor. When the door was tested the doors pushed opened without the use of the exit hardware. An observation of the existing door leafs indicated that vertical exit rods were removed in the past and never reinstalled or replaced. This double door setup lacked the proper number of latching points required for this 2-hour barrier per NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on direct observations it was determined that the facility failed to maintain the closure of the corridor doors per CMS. This deficient practice could affect patient, staff and visitors if a fire would start in this smoke zone, the corridor doors to rooms opening onto the corridor, would not provide a proper smoke barrier for residents to utilize the corridor for egress.

Findings include:

A. On 1/27/2015 at 8:48 AM, while accompanied by E-1 and E-2 an observation on the first floor, Emergency Department, double doors, south door leaf does not latch to the frame when tested. This does not comply with NFPA 101, Section 19.3.6.3 and SOM, Appendix I.

B. On 1/27/2015 at 9:00 AM, while accompanied by E-1 and E-2 an observation on the first floor, Emergency Department, doors into emergency rooms 1, 3 and 4, located on an egress corridor did not latch to the frame when tested. This does not comply with NFPA 101, Section 19.3.6.3 and SOM, Appendix I.

Based on direct observations of hazardous areas, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 1/27/2015 at 9:45 AM while accompanied by E-1 and E-2 an observation on the first floor, surgery suite, determined that the surgery storage room door is warped and did not close and latch to the frame by the use of the door closer. This is not per NFPA 101, section 19.3.2.1.

B. On 1/27/2015 at 10:55 AM while accompanied by E-1 and E-2 an observation on the second floor, west corridor, storage room contained double doors. The south leaf contained manual flush bolts that were not engaged when the door was tested. Properly latching door hardware is required on doors located on egress corridors. Manual flush bolts can be left in the retracted position and so are not considered to be positive latching. Please provide a method of latching these doors that is automatic and which does not require the closure of the active leaf to throw the latch. This does not comply with NFPA 101, section 19.3.2.1.

Based on direct observations and an interview, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect patients, staff and visitors if the egress doors and exit paths prevented exiting from the area in a timely manner during an emergency.

Findings include:

A. On 1/27/2015 at 9:20 AM, while accompanied by E-1 and E-2 an observation determined that the southeast exit door leading to the exterior contained a 4-inch step at the door threshold down to a sand and gravel surface. The required exit does not have a paved surface that continued to, or connected with a sidewalk to a public way as required per NFPA 101, Section 7.1.6.

B. On 1/27/2015 at 9:25 AM, while accompanied by E-1 and E-2 an observation determined that the MRI exit door leading to the exterior contained a 14-inch step at the door threshold down to a gravel surface. The required exit does not have a paved surface that continued to, or connected with a sidewalk to a public way as required per NFPA 101, Section 7.1.6.

C. On 1/27/2015 at 9:28 AM, while accompanied by E-1 and E-2 an observation determined that the east exit door north of the MRI exit door leading to the exterior contained an 8-inch step at the door threshold down to a gravel surface. The required exit does not have a paved surface that continued to, or connected with a sidewalk to a public way as required per NFPA 101, Section 7.1.6.

Based on direct observations, document reviews and interviews, the facility failed to provide proper maintenance, inspections and testing for emergency lights used within the facility. The facility is required to inspect and maintain battery-operated devices. This deficient practice could affect patients, staff and visitors if emergency light did not operate properly during an emergency.

Findings include:

A. On 1/27/2015 10:30 AM, while accompanied by E-1 and E-2, it was determined that on the second floor, nurse station contained 1 emergency exit light that, when tested, did not illuminate. This is not per NFPA 101, Section 7.9.2.4.

B. On 1/27/2015 11:00 AM, while accompanied by E-1 and E-2, it was determined that on the second floor, nurse station adjacent to the cardio lab, contained 1 emergency exit light that, when tested, did not illuminate. This is not per NFPA 101, Section 7.9.2.4.

Based on fire alarm system inspection the facility failed to maintain and inspect the fire alarm system for deficiencies. This deficient practice could affect patients, staff and visitors if a fire were to occur and the fire alarm system devices failed to function properly during a fire emergency.

Findings include: On 1/27/2015 at 9:21 AM, while accompanied by E-1 and E-2 an observation determined that in the x-ray film storage room the acoustical tile ceiling located over the file stacking system has been removed except for one tile which contained a smoke detector. Due to the missing adjacent ceiling tiles the smoke detector location would limit the detectors ability to activate in a timely manner. This does not comply with NFPA 72, section 2-3.4.3.1.

Based on direct observations, documentation reviews and interviews, the facility failed to provide complete required information on quarterly and multi-year tests of the sprinkler system. This deficient practice could affect patients, staff and visitors if the sprinkler system failed to operate properly due to improper maintenance.

Findings include:

A. On 1/27/2015 at 9:21 AM, while accompanied by E-1 and E-2 it was determined by an observation the on the first floor, x-ray storage room, supervisors office contained a broken ceiling tile adjacent to a sprinkler head that was falling out of the ceiling grid. This does not comply with NFPA 13, section 5-6.4.1.1.

B. On 1/27/2015 at 9:21 AM, during quarterly sprinkler inspections and 5-year documentation reviews of the partial sprinkler systems and an interview with E-1 and E-2 it was determined that no information was available to confirm that the Fire Department Connection (FDC) check valve located on the east side of the building has been internally inspected within the last 5-years. This does not comply with NFPA 25, section 9-4.2.1.

C. On 1/27/2015 at 9:22 AM, during quarterly sprinkler inspections and 5-year documentation reviews of the partial sprinkler systems and an interview with E-1 and E-2 it was determined that no documentation was available to confirm that the System Gauges have been replaced or tested within the last 5-years. This does not comply with NFPA 25, section 2-3.2.

D. On 1/27/2015 at 9:24 AM, during quarterly sprinkler inspections and 5-year documentation reviews of the partial sprinkler system and an interview with E-1 and E-2 it was determined that the facility is not conducting and documenting all of the required quarterly sprinkler inspection items per NFPA 25, section 2-2.1, table 2-1 and section 9-1, Table 9-1.

Based on direct observations and interviews, the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system and portable fire extinguishers. This deficient practice could affect patients, staff and visitors in the cafeteria if fire and smoke from a kitchen fire was not contained properly.

Findings include:

On 1/27/2015 at 9:38 AM, while accompanied by E-1 and E-2 an Interview with kitchen staff members determined that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface. Staff training is not in accordance with NFPA 96, section 8-1.4.

Based on direct observations during the survey walk-through, document review, and staff interviews, 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 direct observations, document review and interviews the facility failed to provide a proper enclosure, generator equipment and inspections for the emergency generator set. This deficient practice could affect patients, staff and visitors if the generator failed to function properly or was unable to be shut down due to a malfunction.

Findings include: On 1/27/2015 at 12:40 PM during document review and an interview with E-1 it was determined that the monthly emergency generator testing is not meeting the minimum 30% loading required and therefore would require an annual load back test. The minimum 30% loading is required per NFPA 110, section 6-4.2(a).

Based on direct observations, the facility failed to install and maintain electrical wiring. This deficient practice could affect patients, staff and visitors if power outlets are limited or improperly protected wiring was to result in an electrical fire.

Findings include: On 1/27/2015 at 9:50 AM, while accompanied by E-1 and E-2 it was determined by an observation that on the first floor, Surgery room " A " and " B " does not contain a normal power outlet per NFPA 70, section 517-19 subpart (a).

Based on a direct observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect patients, staff and visitors if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include: On 1/27/2015 at 8:45 AM, while accompanied by E-1 and E-2 an observation on the first floor determined that the designated 2-hour fire double doors between the existing medical office building and the hospital building were deficient. The set of double doors contained one latch point located +/-36-inches above the floor at the exit device. No latching points were identified into the door frame or floor. When the door was tested the doors pushed opened without the use of the exit hardware. An observation of the existing door leafs indicated that vertical exit rods were removed in the past and never reinstalled or replaced. This double door setup lacked the proper number of latching points required for this 2-hour barrier per NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on direct observations it was determined that the facility failed to maintain the closure of the corridor doors per CMS. This deficient practice could affect patient, staff and visitors if a fire would start in this smoke zone, the corridor doors to rooms opening onto the corridor, would not provide a proper smoke barrier for residents to utilize the corridor for egress.

Findings include:

A. On 1/27/2015 at 8:48 AM, while accompanied by E-1 and E-2 an observation on the first floor, Emergency Department, double doors, south door leaf does not latch to the frame when tested. This does not comply with NFPA 101, Section 19.3.6.3 and SOM, Appendix I.

B. On 1/27/2015 at 9:00 AM, while accompanied by E-1 and E-2 an observation on the first floor, Emergency Department, doors into emergency rooms 1, 3 and 4, located on an egress corridor did not latch to the frame when tested. This does not comply with NFPA 101, Section 19.3.6.3 and SOM, Appendix I.

Based on direct observations of hazardous areas, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 1/27/2015 at 9:45 AM while accompanied by E-1 and E-2 an observation on the first floor, surgery suite, determined that the surgery storage room door is warped and did not close and latch to the frame by the use of the door closer. This is not per NFPA 101, section 19.3.2.1.

B. On 1/27/2015 at 10:55 AM while accompanied by E-1 and E-2 an observation on the second floor, west corridor, storage room contained double doors. The south leaf contained manual flush bolts that were not engaged when the door was tested. Properly latching door hardware is required on doors located on egress corridors. Manual flush bolts can be left in the retracted position and so are not considered to be positive latching. Please provide a method of latching these doors that is automatic and which does not require the closure of the active leaf to throw the latch. This does not comply with NFPA 101, section 19.3.2.1.

Based on direct observations and an interview, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect patients, staff and visitors if the egress doors and exit paths prevented exiting from the area in a timely manner during an emergency.

Findings include:

A. On 1/27/2015 at 9:20 AM, while accompanied by E-1 and E-2 an observation determined that the southeast exit door leading to the exterior contained a 4-inch step at the door threshold down to a sand and gravel surface. The required exit does not have a paved surface that continued to, or connected with a sidewalk to a public way as required per NFPA 101, Section 7.1.6.

B. On 1/27/2015 at 9:25 AM, while accompanied by E-1 and E-2 an observation determined that the MRI exit door leading to the exterior contained a 14-inch step at the door threshold down to a gravel surface. The required exit does not have a paved surface that continued to, or connected with a sidewalk to a public way as required per NFPA 101, Section 7.1.6.

C. On 1/27/2015 at 9:28 AM, while accompanied by E-1 and E-2 an observation determined that the east exit door north of the MRI exit door leading to the exterior contained an 8-inch step at the door threshold down to a gravel surface. The required exit does not have a paved surface that continued to, or connected with a sidewalk to a public way as required per NFPA 101, Section 7.1.6.

Based on direct observations, document reviews and interviews, the facility failed to provide proper maintenance, inspections and testing for emergency lights used within the facility. The facility is required to inspect and maintain battery-operated devices. This deficient practice could affect patients, staff and visitors if emergency light did not operate properly during an emergency.

Findings include:

A. On 1/27/2015 10:30 AM, while accompanied by E-1 and E-2, it was determined that on the second floor, nurse station contained 1 emergency exit light that, when tested, did not illuminate. This is not per NFPA 101, Section 7.9.2.4.

B. On 1/27/2015 11:00 AM, while accompanied by E-1 and E-2, it was determined that on the second floor, nurse station adjacent to the cardio lab, contained 1 emergency exit light that, when tested, did not illuminate. This is not per NFPA 101, Section 7.9.2.4.

Based on fire alarm system inspection the facility failed to maintain and inspect the fire alarm system for deficiencies. This deficient practice could affect patients, staff and visitors if a fire were to occur and the fire alarm system devices failed to function properly during a fire emergency.

Findings include: On 1/27/2015 at 9:21 AM, while accompanied by E-1 and E-2 an observation determined that in the x-ray film storage room the acoustical tile ceiling located over the file stacking system has been removed except for one tile which contained a smoke detector. Due to the missing adjacent ceiling tiles the smoke detector location would limit the detectors ability to activate in a timely manner. This does not comply with NFPA 72, section 2-3.4.3.1.

Based on direct observations, documentation reviews and interviews, the facility failed to provide complete required information on quarterly and multi-year tests of the sprinkler system. This deficient practice could affect patients, staff and visitors if the sprinkler system failed to operate properly due to improper maintenance.

Findings include:

A. On 1/27/2015 at 9:21 AM, while accompanied by E-1 and E-2 it was determined by an observation the on the first floor, x-ray storage room, supervisors office contained a broken ceiling tile adjacent to a sprinkler head that was falling out of the ceiling grid. This does not comply with NFPA 13, section 5-6.4.1.1.

B. On 1/27/2015 at 9:21 AM, during quarterly sprinkler inspections and 5-year documentation reviews of the partial sprinkler systems and an interview with E-1 and E-2 it was determined that no information was available to confirm that the Fire Department Connection (FDC) check valve located on the east side of the building has been internally inspected within the last 5-years. This does not comply with NFPA 25, section 9-4.2.1.

C. On 1/27/2015 at 9:22 AM, during quarterly sprinkler inspections and 5-year documentation reviews of the partial sprinkler systems and an interview with E-1 and E-2 it was determined that no documentation was available to confirm that the System Gauges have been replaced or tested within the last 5-years. This does not comply with NFPA 25, section 2-3.2.

D. On 1/27/2015 at 9:24 AM, during quarterly sprinkler inspections and 5-year documentation reviews of the partial sprinkler system and an interview with E-1 and E-2 it was determined that the facility is not conducting and documenting all of the required quarterly sprinkler inspection items per NFPA 25, section 2-2.1, table 2-1 and section 9-1, Table 9-1.

Based on direct observations and interviews, the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system and portable fire extinguishers. This deficient practice could affect patients, staff and visitors in the cafeteria if fire and smoke from a kitchen fire was not contained properly.

Findings include:

On 1/27/2015 at 9:38 AM, while accompanied by E-1 and E-2 an Interview with kitchen staff members determined that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface. Staff training is not in accordance with NFPA 96, section 8-1.4.

Based on direct observations during the survey walk-through, document review, and staff interviews, 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 direct observations, document review and interviews the facility failed to provide a proper enclosure, generator equipment and inspections for the emergency generator set. This deficient practice could affect patients, staff and visitors if the generator failed to function properly or was unable to be shut down due to a malfunction.

Findings include: On 1/27/2015 at 12:40 PM during document review and an interview with E-1 it was determined that the monthly emergency generator testing is not meeting the minimum 30% loading required and therefore would require an annual load back test. The minimum 30% loading is required per NFPA 110, section 6-4.2(a).

Based on direct observations, the facility failed to install and maintain electrical wiring. This deficient practice could affect patients, staff and visitors if power outlets are limited or improperly protected wiring was to result in an electrical fire.

Findings include: On 1/27/2015 at 9:50 AM, while accompanied by E-1 and E-2 it was determined by an observation that on the first floor, Surgery room " A " and " B " does not contain a normal power outlet per NFPA 70, section 517-19 subpart (a).