HospitalInspections.org

Based on interview, observation, and record review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility's main building at 230 Goodman Street, Cincinnati, OH, was determined to have been constructed prior to 2003 and therefore Chapter 19 of the Life Safety Code 101, 2000 edition applies. This has the potential to affect all patients, visitors, and staff to the facility.

Findings include:

K47 failed to have exit and directional signs displayed in accordance with 7.1.
K48 failed to have effective and functional written copies of a plan for the protection of all persons in the event of fire, especially for their evacuation to areas of refuge
K51 failed to have an alarm system that provides an effective warning of fire
K67 failed to have an heating, ventilation and cooling system in compliance with National Fire Protection Association 90A.

Based on interview and record review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility's main building at 230 Goodman Street, Cincinnati, OH, was determined to have been constructed prior to 2003 and therefore Chapter 19 of the Life Safety Code 101, 2000 edition applies. The facility is not in compliance with 19.5.2.1 and therefore Section 9.2 and therefore section 9.2.1 that states the heating, ventilation and cooling and related equipment shall be in accordance with National Fire Protection Association 90A, which states at 2-1.1 equipment shall be arranged to afford access for inspection, maintenance, and repair. On the second floor the facility was not in compliance with 19.2.10.1 and therefore 7.10. This has the potential to affect all patients, visitors, and staff to the facility. The facility's census was 429 patients.

Findings include:

1. Review of the facility's damper inspection report completed from 07/05/12 to 01/11/13 revealed 16 percent of their dampers (smoke and fire inclusive) were inaccessible including three (GSD011, GSD012, and GSD028) in or near the smoke barrier on the west side of radiology. (The radiology department had sustained char damage from smoke during the fire on 10/02/14).

Review of the damper inspection report revealed an inaccessible smoke damper near endoscopy. (The endoscopy suite required evacuation due to the fire.)

On 01/07/15 at 2:50 P.M. in an interview, Staff Q confirmed the dampers in question are inaccessible and of the entire number of dampers hospital wide, 16 percent are inaccessible. He/she stated there isn't any way of knowing when they were tested prior to the testing of the accessible dampers on 07/05/12 to 01/11/13.

On 01/08/05 at 8:45 A.M. in an interview Staff R said he/she could not be certain if the dampers are working.

On 01/08/15 at 8:45 A.M. in an interview, Staff Q and R stated they were unable to determine if the inaccessible dampers on the west side of the radiology department were in the H-VAC system controlling the air flow from air handler 2B-the handler in which a fire occurred on 10/02/14 and which caused smoke damage to the radiology department or if they were located in another air handler unit of the H-VAC system.

Staff R said, "It's like a spider web" of duct work.

2. On 01/07/15 at 11:50 A.M. a tour was conducted of the endoscopy area with Staff S and P. Observation of recovery area 2132 revealed four recovery beds facing three doors in the opposite wall. The path of egress was observed to be through double doors out of sight and perpendicular to the beds. No exit sign was observed directing patients to that path of egress.

On 01/07/15 at 11:50 A.M. in an interview Staff S confirmed the path of egress and the lack of an exit sign on the path of egress.