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Based on observation and interview, the facility failed to provide adequate exit signage in accordance with NFPA 101 - 2012, sections 19.2.10 and 7.10. Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. This deficient practice could affect two patients and an undetermined number of staff and visitors.
19.2.10.1

Findings include:

On July 9, 2018, at 3:22 pm the exit from the surgical clean corridor was not clearly marked. An exit sign was located at a framed opening that had been converted to a storage room. This could create confusion to occupants located in the suite as to where the exit is located.

This deficient practice was confirmed by Staff F at the time of discovery.

Based on record review and staff interview, the facility did not ensure that the fire alarm system is tested in accordance with the requirements of NFPA 101 (2012 edition), Sections 19.3.4 and 9.6.1, NFPA 72, National Fire Alarm and Signaling Code (2010 edition) Sections 14.4.2.2 and 14.4.5. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

On 7/9/2018 at 12:10 pm, a review of the annual fire alarm system test/inspection report documents dated 12-12-2017 stated the batteries were tested. There was no written record for the semi-annual load voltage test of the system batteries.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff E.

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware as required by NFPA 101 (2012 edition), 19.3.6.3. This deficiency had the potential to affect all of the inpatients as well as an undetermined number of staff and visitors.

Findings include:

On 7/9/2018 at 2:22 pm, it was observed in the Zone 1 smoke compartment on the 1st floor that the corridor dutch door leading to the laboratory would not positively self-latch. The upper leaf equipped with a closer and a latch included a surface mounted bolt that prevented the door from latching.

This deficient practice was confirmed by Staff F at the time of discovery.

Based on observation and interview, the facility failed to provide smoke barrier wall construction as required by NFPA 101 - 2012 edition, section 19.3.7.3 and section 8.5. This deficiency had the potential to affect all of the inpatients as well as an undetermined number of staff and visitors.

Findings include:

1. On July 9, 2018 at 1:07 p.m., at the smoke barrier between Zone 2 and Zone 4 smoke compartments in the corridor, revealed that the corner created by the gypsum board above the ceiling was not taped and plastered to maintain the fire barrier.

2. On July 9, 2018 at 1:45 p.m., at the smoke barrier between Zone 2 and Zone 3 smoke compartment in the corridor at the alcove, revealved that the corner created by the gypsum board above the ceiling was not taped and plastered to maintain the fire barrier.

These deficient practices were confirmed by Staff F at the time of discovery.

Based on observation and staff interview, the facility did not ensure that the emergency power system is installed in accordance with the requirements of NFPA 101 (2012 edition), Sections 19.5.1.1 and 9.1.2, NFPA 70, National Electrical Code (2011 edition) Section 700.10 (A). This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

On 7/9/2018 at 2:55 pm, observation in the Zone 4 mechanical room revealed three emergency power transfer switch enclosures identified with signage that was of the same type, style, and color as the normal power enclosure panels.

This deficiency was confirmed at the time of discovery by concurrent interview with Staff E.

Based on observation and staff interview, the facility did not ensure that extension cords are not used as a substitute for fixed wiring of a structure and that extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed, per NFPA 99 (2012 edition), 10.2.4 and NFPA 70 (2011 edition), 400.8. This deficient practice could affect all inpatients and an undermined number of staff and visitors.

Findings include:

1. On 7/9/18 at 12:47 pm, observation revealed within Zone 2 smoke compartment in the Dietician Office that an extension cord was used to power an air freshener.

2. On 7/9/18 at 1:12 pm, observation revealed within Zone 4 smoke compartment in the Physical Therapy Director's Office that a multi-plug device was installed to provide additional plug capacity for appliances.

These deficient practices were confirmed by Staff F at the time of discovery.