HospitalInspections.org

Based on observation and interview the facility failed to ensure egress doors were accessible in the event of an emergency situation. Specifically, the use of magnetic door holds that do not release with activation of the fire alarm or sprinkler system and exit signage directing individuals towards the magnetically held doors located in the main building lobby, the 2nd floor Hodge building maternity unit waiting area and the 3rd floor Hodge building Obstetrics/Gynecology outpatient clinic were present. This has the potential to prevent patients, staff and visitors from exiting the areas in the event of a fire.

Findings include:

Observation on 05/07/19 at 03:15 PM in the 3rd floor Obstetrics/Gynecology (OB/GYN) outpatient clinic revealed a door in the corridor with an exit sign above it, that was secured with a magnetic hold. Interview with Staff (VV), Facilities indicated the door separated the OB/GYN clinic from a private practice and the clinic was not sprinklered. There is no clinical need to secure these doors.

Observation on 05/07/19 at 03:30 PM in the 2nd floor Hodge building maternity waiting area revealed an exit sign located above the doors entering the maternity unit, that directed persons in the maternity waiting area to exit through the maternity unit. Interview with Staff (VV), Facilities indicated that the magnetic lock did not drop out with the fire alarm system. Interview at 05:30 PM with Staff (LLL), Director of Facilities indicated revealed a fire alarm report that indicated that the magnetic hold on the maternity unit doors drop out with activation of the fire alarm system could not be located.

Observation on 05/07/19 at 04:00 PM in the main building lobby revealed a set of double doors with magnetic holds. Interview with Staff (A), Vice President and CNO indicated that the doors are secured with the magnetic holds between 08:00 PM - 06:00 AM. The doors have an exit sign directing people from the lobby to the stairwell. The magnetic holds prevent people from utilizing this path of egress. The area is not fully sprinklered and there is no clinical need to secure these doors.

Interview on 05/07/19 at 04:45 PM with Staff (T), Chief Operating Officer verified these findings.

Based on observation and interview the facility did not maintain stairway identification in 2 of 2 stairways in the S-building.

Findings include:

During the facility tour on 05/07/2019 at 2:30 PM, it was revealed that the exit stairways in the S-building did not include signage on each floor of the stairway indicating the stairway name, what floor the exit discharge is on and the direction to the discharge floor.

This finding was verified with Staff (VV), Facilities on 05/07/2019 at 2:30 PM.

Based on observation and interview the facility does not maintain all emergency lighting.

Findings include:

Observation on 05/07/2019 at 11:15 AM in the 2nd floor of the S-building revealed six (6) of ten (10) battery pack emergency lights that were mounted in the corridors did not illuminate when the test button was pressed.

Interview on 05/07/2019 at 11:15 AM with Staff (VV), Facilities verified this finding.

Based on document review, observation and interview the facility does not maintain fire barriers protecting hazardous areas.

Findings include:

Review of facility life safety plans revealed the wall separating the mechanical room from the corridor on the 7th floor of the S-building is a 2-hour rated barrier.

Observation on 05/10/19 at 10:00 AM on the 7th floor of the S-building revealed the wall separating the mechanical room from the corridor had three pipe sleeves penetrating the block concrete wall. The space between the pipe sleeves was not fire stopped. The size of the penetration was approximately 3-feet by 1.5 feet.

Interview on 05/10/19 at 10:00 AM with Staff (UU), Maintenance Coordinator verified this finding.

Based on observation and interview the facility did not fire protect the Tenth Street Cafe.

Findings include:

Observation on 05/07/19 at 05:45 PM at the Tenth Street Café, located in the service building of the hospital revealed an open corridor which is not fire protected. The opening to the corridor and the cafe is 12-feet wide by 8-feet high and the smoke compartment is not fully sprinklered. There are two deep fat fryers (prohibited), a pizza oven and seating for 82-persons (30 or under persons).

Interview on 05/07/19 at 05:45 PM with Staff (LLL), Director of Facilities verified this finding and indicated that a certificate of need was not submitted or required. Cannon Design designed the Café and installed four sprinklers, two sprinklers on each side of the header at the entrance of the Café.

Based on document review, observation and interview the facility did not maintain all smoke barriers.

Findings include:

Observation on 05/10/19 at 10:00 AM on the 7th floor of the S-building revealed a glass partition at the nursing station, approximately 4 feet by 4 feet with a sliding glass window. The glass had no indication of a rating. The floor houses intensive care unit patients and is partially sprinklered.

Observation on 05/10/19 at 10:00 AM on the 2nd floor of the S-building revealed a large penetration above the double doors by the soiled utility room. The penetration had numerous Cat-5 cables running through it and was stuffed with mineral wool but was not sealed. The floor houses medical/surgical patients and is not sprinklered.

Review of the facility life safety plans revealed that the above noted areas are identified as part of the 1-hour smoke barrier that divides the compartment.

Interview on 05/10/19 at 10:00 AM with Staff (UU), Maintenance Coordinator verified these findings.