HospitalInspections.org

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the recovery suite in a smoke compartment with an automatic sprinkler system. Findings include:

1. Observation at 1:00 p.m. revealed the double-doors from the corridor to the recovery suite would not positively latch into the frame. The automatic dead bolt on the inactive leaf was broken and would not latch into the frame when the door was in the closed position. Interview with the maintenance supervisor at the time of the observation confirmed the finding.

Based on observation and interview, the provider failed to maintain the fire-resistive rating of one of four stair enclosures with construction having a fire-resistance rating of at least one hour. Findings include:

1. Observation at 10:30 a.m. revealed the door to the south stair enclosure on the second floor was missing the door closer. Interview with the maintenance supervisor at the time of the observation indicated he was unaware the door closer was missing. He was aware that a door closer was necessary to maintain the fire resistive rating of the vertical separation.

Based on observation and interview, the provider failed to maintain proper separation of three randomly observed hazardous areas. The double-doors to the maintenance suite, materials storage, and laundry would not positively latch into the frame. Findings include:

1. Observation at 9:15 a.m. revealed the double-doors from the corridor to the maintenance suite would not positively latch into the frame. Interview with the maintenance supervisor at the time of the interview indicated the automatic flush bolt on the inactive leaf was not properly adjusted. The doors were recently installed by an outside contractor and were not identified during the hospital final inspection.

2. Observation at 9:30 a.m. revealed the double-doors from the corridor to the materials storage suite would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the automatic flush bolt on the inactive leaf was not operating properly.

3. Observation at 9:45 a.m. revealed the double-doors from the north exit of the laundry would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the automatic flush bolt on the inactive leaf was out of adjustment. He also indicated more routine inspections of the fire rated door assemblies would be necessary.

Based on observation and document review, the provider failed to maintain at least two conforming exits from each floor of the building. The exit from the east current medical record storage basement and the exit from the elevator pit basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress (stair enclosure) and each means of egress opened onto the main floor corridor system instead of directly outside. Findings include:

1. Observation at 10:00 a.m. revealed two basement areas were not provided with an approved means of egress. The exit from the east current medical record storage basement and the exit from the elevator mechanical room basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress and each means of egress opened onto the main floor corridor system instead of directly outside. Document review of previous survey data indicated that condition was part of the original construction.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain a one hour fire-resistive path of egress from the basement to the exterior of the building. The east basement stairway from the archived medical record storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged onto the main level corridor system. Findings include:

1. Observation beginning at 1:30 p.m. revealed the east basement stairway from the archived medical records storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged into the main level corridor system. Interview with the maintenance supervisor at the time of the observations confirmed those findings. He stated the stair enclosures were part of the original construction or were boxed in from construction additions.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. One randomly observed cross-corridor horizontal exit door separating the attached nursing home from the hospital would not positively latch into the frame. Findings include:

1. Observation and testing beginning at 4:15 p.m. revealed the 90 minute fire rated cross-corridor horizontal exit doors separating the nursing home from the hospital would not positively latch into the frame. The north leaf was out of adjustment and not activating the latching mechanism upon closing. Interview with the director of plant operation during the exit conference indicated those doors were just serviced by an outside contractor and should have been operating properly.

Based on observation and interview, the provider failed to ensure the staff person responding to the simulated fire was familiar with fire drill procedures. Findings include:

1. Observation at 1:30 p.m. revealed the charge nurse responding to the fire did not activate the fire alarm system for approximately six minutes following discovering the simulated fire. She closed the door, announced the overhead page, and began closing the remainder of the corridor doors. She appeared confused as to why other employees were not responding to the fire drill. Following the simulated extinguishment of the fire she finally realized her mistake and activated the fire alarm. That triggered an overhead page by the hospital switch board and multiple staff arrived at the location. Interview with the maintenance supervisor at the time of the fire drill confirmed the policy was to activate the fire alarm immediately following evacuation of the room and closing the door.

I. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted on 1/24/12. Brookings Hospital Yorkshire Eye Clinic was found not in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

A. Based on observation, testing, and interview, the provider failed to maintain battery operated emergency lighting. Two of two emergency lights would not operate when tested. Findings include:

1. Observation and testing at 2:50 p.m. revealed both sets of battery powered emergency lights located in the corridor would not operate when tested. Interview with the maintenance supervisor at the time of the observation confirmed the lights would not operate. He indicated this building was recently added as a provider based clinic and maintenance had not been testing the lights.

II. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted on 1/24/12. Brookings Hospital Sleep Lab was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the recovery suite in a smoke compartment with an automatic sprinkler system. Findings include:

1. Observation at 1:00 p.m. revealed the double-doors from the corridor to the recovery suite would not positively latch into the frame. The automatic dead bolt on the inactive leaf was broken and would not latch into the frame when the door was in the closed position. Interview with the maintenance supervisor at the time of the observation confirmed the finding.

Based on observation and interview, the provider failed to maintain the fire-resistive rating of one of four stair enclosures with construction having a fire-resistance rating of at least one hour. Findings include:

1. Observation at 10:30 a.m. revealed the door to the south stair enclosure on the second floor was missing the door closer. Interview with the maintenance supervisor at the time of the observation indicated he was unaware the door closer was missing. He was aware that a door closer was necessary to maintain the fire resistive rating of the vertical separation.

Based on observation and interview, the provider failed to maintain proper separation of three randomly observed hazardous areas. The double-doors to the maintenance suite, materials storage, and laundry would not positively latch into the frame. Findings include:

1. Observation at 9:15 a.m. revealed the double-doors from the corridor to the maintenance suite would not positively latch into the frame. Interview with the maintenance supervisor at the time of the interview indicated the automatic flush bolt on the inactive leaf was not properly adjusted. The doors were recently installed by an outside contractor and were not identified during the hospital final inspection.

2. Observation at 9:30 a.m. revealed the double-doors from the corridor to the materials storage suite would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the automatic flush bolt on the inactive leaf was not operating properly.

3. Observation at 9:45 a.m. revealed the double-doors from the north exit of the laundry would not positively latch into the frame. Interview with the maintenance supervisor at the time of the observation confirmed the automatic flush bolt on the inactive leaf was out of adjustment. He also indicated more routine inspections of the fire rated door assemblies would be necessary.

Based on observation and document review, the provider failed to maintain at least two conforming exits from each floor of the building. The exit from the east current medical record storage basement and the exit from the elevator pit basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress (stair enclosure) and each means of egress opened onto the main floor corridor system instead of directly outside. Findings include:

1. Observation at 10:00 a.m. revealed two basement areas were not provided with an approved means of egress. The exit from the east current medical record storage basement and the exit from the elevator mechanical room basement did not meet the standard for means of egress. Each of the two basement locations only had one means of egress and each means of egress opened onto the main floor corridor system instead of directly outside. Document review of previous survey data indicated that condition was part of the original construction.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain a one hour fire-resistive path of egress from the basement to the exterior of the building. The east basement stairway from the archived medical record storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged onto the main level corridor system. Findings include:

1. Observation beginning at 1:30 p.m. revealed the east basement stairway from the archived medical records storage, the east stair enclosure from the obstetrics department on the second level, and the north stair enclosure from the medical wing of the second level discharged into the main level corridor system. Interview with the maintenance supervisor at the time of the observations confirmed those findings. He stated the stair enclosures were part of the original construction or were boxed in from construction additions.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. One randomly observed cross-corridor horizontal exit door separating the attached nursing home from the hospital would not positively latch into the frame. Findings include:

1. Observation and testing beginning at 4:15 p.m. revealed the 90 minute fire rated cross-corridor horizontal exit doors separating the nursing home from the hospital would not positively latch into the frame. The north leaf was out of adjustment and not activating the latching mechanism upon closing. Interview with the director of plant operation during the exit conference indicated those doors were just serviced by an outside contractor and should have been operating properly.

Based on observation and interview, the provider failed to ensure the staff person responding to the simulated fire was familiar with fire drill procedures. Findings include:

1. Observation at 1:30 p.m. revealed the charge nurse responding to the fire did not activate the fire alarm system for approximately six minutes following discovering the simulated fire. She closed the door, announced the overhead page, and began closing the remainder of the corridor doors. She appeared confused as to why other employees were not responding to the fire drill. Following the simulated extinguishment of the fire she finally realized her mistake and activated the fire alarm. That triggered an overhead page by the hospital switch board and multiple staff arrived at the location. Interview with the maintenance supervisor at the time of the fire drill confirmed the policy was to activate the fire alarm immediately following evacuation of the room and closing the door.

I. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted on 1/24/12. Brookings Hospital Yorkshire Eye Clinic was found not in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.

A. Based on observation, testing, and interview, the provider failed to maintain battery operated emergency lighting. Two of two emergency lights would not operate when tested. Findings include:

1. Observation and testing at 2:50 p.m. revealed both sets of battery powered emergency lights located in the corridor would not operate when tested. Interview with the maintenance supervisor at the time of the observation confirmed the lights would not operate. He indicated this building was recently added as a provider based clinic and maintenance had not been testing the lights.

II. A recertification survey for compliance with the Life Safety Code (LSC) 2000 Edition, Existing Business Occupancy was conducted on 1/24/12. Brookings Hospital Sleep Lab was found in compliance with 42 CFR 482.41 (b) (1) requirements for hospitals.