HospitalInspections.org

REMAINS CITED

Based on observation and staff interviews and verification, the facility failed to ensure one exit access was arranged to ensure a continuous surface between the exit discharge and the public way. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds.

Findings include:

On 01/16/14 between 9:00 A.M. and 12:00 P.M. tour of the facility for the post survey revisit (PSR) was conducted with Staff A, B and C. Observations of the exit discharge from Stairwell CC revealed a concrete pad outside the exit door. The pad was approximately 4 feet by 4 feet in diameter. Further observation of the area beyond the concrete pad revealed a recently poured concrete sidewalk. In addition workers were in the area working at forming and preparing the steep grade for concrete steps that would lead to the public way.

During a tour of the facility conducted on 11/13/13 at 10:20 A.M. the area from the concrete pad was observed to be a steep grade approximately 50 feet to the public way. The steep grade was observed with smaller rocks and minimal grass.

Interview of Staff B at the observation of the project on 01/16/14 verified the concrete for the side walk was just poured and the project was ongoing in order to complete the exit passageway. Staff B verified the steps and the handrails for the steps still needed to be completed.

The floor evacuation plans revealed this exit discharge was used by patients, staff, and visitors in the Same Day Surgery building, the Emergency Department building, and the lower level of the main hospital building. While the sidewalk project was ongoing , an alternate path of egress was established and clearly marked from the building.

The former exit discharge was present before the addition of the Emergency Department (ED) building, and the hillside was made steeper with the addition of the ED building. Staff B verified the exit to the public was an oversight.






03245

REMAINS CITED

NFPA 101

Chapter 21

Ambulatory health care occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Doors in such barriers are solid bonded core wood of 1 inches or equivalent and are equipped with a positive latch and closing device.

Based on facility observation review of facility documentation and staff interview and verification, the facility failed to ensure the ambulatory health care occupancies was separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. The facility had a capacity for 1061 patients. Potentially all patients, visitors and staff could be affected.

Findings included:

On 01/16/14 between 9:00 A.M. and 3:00 P.M. tour of the facility for the PSR was conducted with Staff A, B and C. Review of the plan of correction documentation for the survey completed 11/14/13, revealed the facility wished to appeal the deficiency cited.

Interview of Staff A and B at the time of the tour, revealed the staff felt the building where the ambulatory surgery center was located was compliant and verified that no changes had been made to the areas of the building as observed during the previous life safety code survey completed on 11/14/13. The ambulatory surgery center remained as observed and described below:

1. On 11/12/13 at 12:45 P.M. observations above the ceiling tiles with Staff AA and MM were conducted of an identified one hour fire rated separation between the ASC and the Breast Health Center. The following penetrations were noted in the one hour fire rated barrier;

Located above the ceiling tiles in the ASC waiting area, a penetration surrounding a gray IT wire and a second penetration approximately one half inch in diameter.

Located in the one hour fire rated barrier was a non-fire rated window for the breast health receptionist. Observation above the ceiling tiles at the same reception window revealed penetrations surrounding copper pipe and a black wire.

Observation above the ceiling tiles at the ASC waiting room desk, revealed a penetration approximately 12 inches long and four inches wide near a large duct.

Observation above the ceiling tiles at the endoscopy nursing station, revealed the end of the one hour fire rated barrier. The space above the ceiling was open and no additional fire rated separation was observed. Staff present verified the observation.

On 11/14/13 at 10:00 A.M., Staff BB stated the schematic for the ASC was misread and that no one hour fire rated barrier existed between the ASC and the Breast Health Center.