HospitalInspections.org

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Based on observation and interview the facility failed to ensure exit egress was arranged in a manner that prevented occupant from exiting through a hazardous area in accordance with NFPA 101: 7.5.1.6. This failed practice placed occupants in the outpatient surgical center at risk for exposer to a hazardous room during egress. Findings:

Observation on 4/5/17 at 2:30 pm revealed an area, identified as a vestibule greater than 50 ft2, contained a 48 lbs. biohazardous waist container and a 64 gallon soiled linen cart. This room was located at the end of a corridor that harbored scope washing areas, general storage, dressing rooms and staff lounge. Egress markings indicated occupants were to exit the corridor through this vestibule before reaching the exit discharge to the exterior.

The Facilities Director confirmed the finding at the time of discovery.
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Based on observation and interview the facility failed to ensure one room (room 10) in the emergency department was free from locking mechanisms in accordance with NFPA 101: 19.2.2.2 and one behavioral health room (room 1) unlocked with the activation of the fire alarm and/or sprinkler system in accordance with NFPA 101: 19.2.2.2.5.2(5)(a)(b). These failed practices placed occupants in rooms 1 and 10 at risk for delayed egress and prolonged exposure to a smoke and/or fire environment. Findings:

Observation of the emergency department on 4/6/17 revealed rooms 1 (behavioral health) and 10 (normal patient care room) contained locking devices.

During an interview on 4/6/17 the Facilities Manager confirmed room 1 does not unlock with the activation of the fire alarm system. In addition, the Manager stated room 10 would require a key to access the patient. The charge nurse would have to be contacted and brought to the medication room to retrieve keys to unlock room 10.

Review of NFPA 101: 19.2.2.2.5.2(5)(a)(b) states "Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met: ...(5) The locks release by independent activation of each of the following: (a) Activation of the smoke detection system required by 19.2.2.2.5.2(2) (b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)."
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Based on observation and interview the facility failed to ensure a set of fire doors were operating in a fashion to prevent the spread of fire and smoke in a hazardous area in accordance with NFPA 101: 19.3.2. The failed practice placed all occupants at risk for loss of utilities and 1 out of 12 smoke compartments at risk for accelerated fire spread. Findings:

Observation on 4/6/17 at 11:00 revealed a ¾ hour fire rated door separating the mechanical space containing boilers and the mechanical space containing medical gas supply that did not shut and latch appropriately.

Review of the facilities architectural maps, dated 2/9/11, and revealed the door was located within a 1 hour fire barrier.

The Facilities Director acknowledged the finding at the time of discovery.
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Based on observation and interview the facility failed to ensure central kitchen hood suppression systems were maintained in accordance with NFPA 96: 10.2.6 as referenced by NFPA 101: 19.3.2.5. Specifically, the facility failed to ensure blow-off caps were in place and suppression nozzles were appropriately installed to provide adequate coverage of the deep-fat fryer. This placed all occupants at risk for loss of food service and placed 1 out 8 smoke compartments, located on the main hospital's first floor, at risk for exposure to a fire/smoke environment. Findings:

Observations from 4/5-6/17 revealed the hoods suppression system nozzles, located on the serving line of the café, were not covered by blow-off camps. Further observation revealed each nozzle had a blow-off cap that was hanging off the tip of the nozzle with an accumulation of dark brown liquid that was actively dripping off the nozzle's tip. In addition, the central kitchen contained a 2 sided deep fat fryer. The two nozzles designed to protect the fryer were improperly positioned to suppress any grease fire. One nozzle was not pointing at the fryer and the other nozzle was hitting the center division line of the fryer.

The Facilities Director acknowledged the findings at the time of their discovery.
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Based on observation and interview the facility failed to ensure alcohol-based hand-rubs (ABHR) dispensers were installed in compliance with NFPA 101: 19.3.2.6. Specifically, the facility failed to ensure ABHR dispensers were installed away from electrical sources. This failed practice occupants in 2 out of 12 smoke compartments in the main hospital at risk for increased fire potential and exposure to accelerated fire development. Findings:

Observation of the emergency department on 4/6/17 at 9:19 am revealed an ABHR dispenser installed over an outlet in exam room 10.

Observation of the fluoroscopy area on 4/6/17 at 10:15 am revealed an ABHR dispenser installed over an outlet.

The Facilities Director acknowledged these findings at the time of their discovery.
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Based on observation and interview the facility failed to ensure sprinkler heads located in the emergency department were free from obstructions per NFPA 13: 8.6.5.2 as referenced by NFPA 101: 19.3.5.3. This failed practice placed occupants in 1 out of 8 smoke compartments at risk for exposure to smoke and/or fire environment as a result of obstructed spray patterns. Findings:

Observations on 4/6/17 at 9:00 am revealed emergency room beds 7, 8 and 9 were located in a single room within the emergency department. Each bed had a light installed above the bed used for examination. The base of the light was approximately 10 inches in depth and hung from the ceiling. Further observation revealed a sprinkler head located within a couple of inches and centered next to the light's base.

These findings were acknowledged by the Facilities Director at the time of their discovery.
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Based on observation and interview the facility failed to ensure corridor doors that protected the corridor were maintained in a manner to prevent the passage of smoke per NFPA 101: 19.3.6.3. This failed practice placed all occupants in 3 out 12 smoke compartments, located at the main hospital, at risk for exposure to smoke and/or fire environment.

Random observation of the main hospital's second floor on 4/5/17 revealed the following rooms did not shut accordingly to prevent the passage of smoke: 221, 223, 237 and the case management office.

Observation of the cafeteria on 4/5/17 at 4:35 pm revealed a set of double doors located at the far end of cafeteria. Further observation revealed the door had a center gap greater than ¼".

Review of the facility architectural plans, dated 2/9/11, revealed the cafeteria door was located in a smoke barrier.

The Facilities Director acknowledged the findings at the time of their discovery.
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Based on observation and interview the facility failed to ensure a fire/smoke barrier was free from unprotected penetrations in accordance with NFPA 101: 8.5.6. This failed practice place 2 out of 4 smoke compartments within the main hospital's second floor, and at risk for exposure to a smoke and fire environment. Findings:

Observation of the main hospital's second floor on 4/5/17 at 11:45 am revealed an unprotected penetration located above cross corridor doors next to room 233.

Review of the facility's architectural plans, dated 2/9/11, revealed the penetrated barrier was a one hour fire barrier that resists the passage of smoke.

The Facilities Director acknowledged this finding at the time of its discovery.
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Based on observation and interview the facility failed to ensure outlets within a wet location are ground fault-interrupter protection (GFCI) per NFPA 70: 210.8. This failed practice placed occupants in 2 of 12 smoke compartments in the main hospital at risk for electrocution and/or increased fire potential. Findings:

Observation of the obstetric nourishment room on 4/6/17 at 11:20 am revealed a non-GFCI outlet located within 6 inches of the sink.

Observation of the post-operative nourishment room on 4/6/17 at 11:40 am revealed a non-GFCI outlet located within 6 inches of the sink.

The Facilities Director acknowledged these findings at the time of their discovery.
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