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Based on observation during the survey walk-through, not all exit discharges are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their ability to exit the building could be impeded if the exit discharges are not compliant.

Findings include:

On March 1, 2018 at 8:30 AM, while accompanied by the DQ, observation determined that the east exterior egress path, from the southeast corner of the Helipad to the adjacent drive, is not complete to a public way as required by 7.7.1 because the distance between the Helipad and the drive is not paved.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

On March 1, 2018 at 9:03 AM, while accompanied by the DQ, observation determined that the door to the Emergency Department Storage Room is not self-closing as required by 19.3.2.1.3 and Table 8.3.4.2.

Based on observation during the survey walk-through, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor doors are not properly installed and maintained.

Findings include:

A. On March 1, 2018 at 8:58 AM, while accompanied by the DQ, observation determined that the door frame for the Laboratory Phlebotomy Room does not constitute a labeled steel frame, as required by 19.3.6.3.14, because holes in the frame have not been repaired.

B. On March 1, 2018 at 8:57 AM, while accompanied by the DQ, observation determined that the door to the Laboratory Microbiology Room does not constitute a solid-bonded wood core door, as required by 19.3.6.3.1(1), because holes in the door have not been repaired.

Based on document review, the facility failed to conduct periodic fire drills as required. This deficient practice could affect patients, staff, and visitors in the hospital because the hospital staff may not be properly prepared for a fire emergency if fire drills are not conducted properly.

Findings include:

On March 1, 2018 at 10:06 AM, while accompanied by the DQ, document review determined that fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.4. Fire drills for which no signal was transmitted during the calendar year 2017 include:
A. January 15, 2017.

B. December 26, 2017.

Based on document review, not all fire doors and other required door assemblies are periodically inspected and tested. This deficient practice could affect patients, staff, and visitors in the building because the doors could fail to operate properly under emergency conditions, thus either impeding egress or permitting fire and smoke to pass between fire or smoke compartments if the doors are not properly maintained.

Findings include:

On February 28, 2018 at 2:25 PM, while accompanied by the DQ, document review determined that the inspection of fire door and other required door assemblies is not conducted and documented as required by NFPA 80 2010 5.2.1.