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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the cited rooms to the building's corridors.

Findings include:

A. 08/21/2014 at 12:40pm Doors in exit access corridors were observed that are not positive latching to comply with 18.3.6.3.2. Locations observed include:
1. The sliding doors to exam rooms and the trauma room within the E.D. (it was unknown due to the lack of suite designations on the Facility provided Life Safety floor plan if the E.D. and other areas constituted a suite to comply with 18.2.5.7).

Based on document review of plans and based on discussions with the Facilities representative the surveyor finds that designated smoke compartments do not comply with 18.3.7.1. Failure to identify and maintain required smoke barriers could allow smoke to spread beyond the compartment of fire origin.

Findings include:

A. 08/21/2014 at 11:00am Due to the lack of indicated smoke barriers on the Facility provided Life Safety Plans it appears that the travel distance from one smoke compartment to the next exceeds the allowable maximum distance to comply with 18.3.7.1 (4).

1. It appears that PT, Respiratory Therapy, Lab, X-ray, Boiler, Chiller, Generator and part of the 2010 Med/Surg addition are all located within one large smoke compartment. The Facility representative was unable to identify a smoke barrier within this area to comply with 18.3.7.1. Therefore, this area is a noncompliant smoke compartment due to the following:

a. A smoke compartment is required to divide every story having an occupant load of 50 or more persons into not less than two compartments to comply with 18.3.7.1 (2).

B. 08/21/2014 at 11:00am The facility representative was not able to identify the square footage of any smoke compartment within the facility to comply with the size limit in accordance with 18.3.7.1(3).

A. Based on an observation of hazardous areas the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

1. 08/21/2014 at 1:15pm Storage room within the E.D. adjacent to the E.M. work room lacks self closing door hardware.

2. 08/21/2014 at 1:35pm Clean supply room within the ED behind the nurse station lacks self closing door hardware.

3. 08/21/2014 at 2:10pm Chiller room lacks a self closing, fire resistant labeled door.

4. 08/21/2014 at 2:35pm I.T. room (referred to as computer room) lacks self closing door hardware.

5. 08/21/2014 at 2:45pm Staff Break room (located across the corridor from Receiving) door into the Vending machine room ( this room is designated storage on the Life Safety floor plans and contains items stored within) lacks self closing hardware.

6. 08/21/2014 at 3:00pm Respiratory Therapy Locker/Storage room lacks self closing door hardware on both doors. The door closer's were observed with missing main arm assemblies. The door to the patient care hallway was wedged open with a storage box.


B. 08/21/2014 at 2:45pm Wall between Staff Break Room and storage room (former kitchen) contains pipe penetration which are not sealed against the passage of smoke and fire to maintain the fire resistance rating of the wall. The location of the holes is in the west end of this wall.


C. 08/21/2014 at 2:05pm Wall between the Med/Gas storage room (located within the Chiller room) and the Surgery janitor closet contains holes and penetrations which are not sealed against the passage of smoke and fire to maintain the 1-hour fire resistance rating of the wall.


D. Rooms or areas currently being used for storage, not shown as designated hazardous areas on the facility Life Safety floor plan, are not protected to comply with 18.3.2.1. for areas forming a hazard greater than that of the normal occupancy. Example locations include:

1. 08/21/2014 at 2:20pm Respiratory Therapy room directly connected to means of egress corridor appears to be an exam room, however, surveyor observed that it is being used for storage. The doors lack self closing hardware.

a. This same room is not designated as hazardous on the Life Safety floor plan and is not enclosed with 1-hour fire resistant walls for storage rooms larger than 100 s.f.

2. 08/21/2014 at 2:23pm Pharmacy IV room surveyor observed that it is being used for storage. The corridor door lacks self closing hardware.

a. This same room is not designated as hazardous on the Life Safety floor plan and is not enclosed with 1-hour fire resistant walls for storage rooms larger than 100 s.f.

Based on random observation during the survey walk-through and document review the use of the suite concept does not comply with 18.2.5.2 - 2.5.8. During discussion with the Facility representative, the size, location and suite perimeters could not be confirmed. The lack of distinction between an aisle (allowed to contain items, may also have one direction of egress) or a corridor that contains two remote means of egress could prevent patients, staff and visitors from exiting an area of the building in a safe manner during a fire/smoke event.

Findings include:

A. 08/21/2014 at 11:00am the surveyor questioned the facility's use of suites to comply with 18.2.5. The surveyor was informed that the E.D., Surgery, and Pre-Op/Recovery are suites however the following was not confirmed by the facility:

1. The square foot size of any suites to comply with 18.2.5.2 and 2.5.3.

2. The available means of egress from any suite to a corridor to comply with 18.2.5.1.

3. The number and type (no hazardous areas) of any intervening rooms to comply with 18.2.5.5.

Based on random observation during the survey walk-through while accompanied by engineering staff, battery powered emergency illumination is not provided to comply with 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2 for locations of anesthetized patients. This deficiency could affect any patients, staff, or visitors on this floor level because the failure of the normal lighting could prevent them from safely exiting the building under fire conditions.

Findings include:


A. 08/21/2014 at 1:22PM Operating rooms were observed to not be provided with battery powered emergency lighting to comply with NFPA 99-1999, 3-3.2.1.2(a)5(e). During an interview held with the Facility representative. the surveyor was informed that the Operating Rooms contained ballasted battery backup emergency lighting. However, none of these are checked and tested to comply with NFPA 99. This same situation occurs in Pr-Op/Recovery and the E.D. Trauma room.

During the survey walk-through while accompanied by facility representatives, the surveyor observed paths of egress that were not identified by exit signage to comply with 18.2.10 and 7.10.2. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:

A. Exit routes are not clearly defined to comply with 18.2.10. Conditions observed include but are not necessarily limited to the following:

1. 08/21/2014 at 12:20pm Exit signage is not present in the Pre-Op, Recovery area that indicate an exit path to the nearest corridor to comply with 18.2.5.

2. 08/21/2014 at 2:15pm The exit sign at the corridor intersection adjacent to Lab and the north corridor leading to the Boiler room has a directional arrow with the indicated direction that is not appropriate and does not comply with 18.2.3.3 for corridor width requirements in a hospital.

3. 08/21/2014 at 1:50pm Exit signage to identify the 2nd available exit path in the O.R. corridor is not provided. Further, if this is a "suite" to comply with 18.2.5.2 or 18.2.5.3 then the second remotely located exit access is not designated.

Based on random observation during the survey walk-through accompanied by the Head of Maintenance, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

The finding is:

A. 08/22/2014 at 9:30am The fire shutter for the Pharmacy pass-through window did not close upon activation of the fire alarm under either detector activations or pull station activation.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 18.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1.
These deficiencies could affect any patients, staff, or visitors in the immediate area by preventing the timely activation of the sprinkler heads.

Findings include:

A. 3:00pm 08/21/2014: Electrical Closet (within the 2010 MedSurg building addition between room numbers 306 and 307) was observed to lack sprinkler protection to comply NFPA 13 1999 5-6.4.1.1.

B. 3:30pm 08/21/2014 Receiving area located adjacent to the Boiler room contains sprinkler piping that lacks bracing spaced to comply with NFPA 13.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99 1999, 8-3.1.11.2(c)(2). These deficiencies could affect any patients, staff, or visitors in the immediate area because the oxygen could contribute to an ongoing fire.

Findings include:

A. Oxygen tanks stored in sprinklered areas are not separated by minimum 5'-0" from combustibles. Locations observed include but are not necessarily limited to the following:

1. 08/21/2014 2:25pm at Storage room within Respiratory Care (observed 13 tanks) less than 5'-0" from combustible cardboard boxes and plastics.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's emergency electrical system are tested in accordance with NFPA 110 1999. Failure to test and document operating parameters for comparison to previous readings can cause an impending failure of the system to go un-noticed.

Findings include;

A. 08/22/2014 at 10:15am During the document review process, it was determined that the only available documentation of the weekly emergency generator inspection was a written log of the weeks. There is no written record of which components for the emergency generator were visually inspected each week to comply with NFPA 110 1999 6-4.1.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to pass from the cited rooms to the building's corridors.

Findings include:

A. 08/21/2014 at 12:40pm Doors in exit access corridors were observed that are not positive latching to comply with 18.3.6.3.2. Locations observed include:
1. The sliding doors to exam rooms and the trauma room within the E.D. (it was unknown due to the lack of suite designations on the Facility provided Life Safety floor plan if the E.D. and other areas constituted a suite to comply with 18.2.5.7).

Based on document review of plans and based on discussions with the Facilities representative the surveyor finds that designated smoke compartments do not comply with 18.3.7.1. Failure to identify and maintain required smoke barriers could allow smoke to spread beyond the compartment of fire origin.

Findings include:

A. 08/21/2014 at 11:00am Due to the lack of indicated smoke barriers on the Facility provided Life Safety Plans it appears that the travel distance from one smoke compartment to the next exceeds the allowable maximum distance to comply with 18.3.7.1 (4).

1. It appears that PT, Respiratory Therapy, Lab, X-ray, Boiler, Chiller, Generator and part of the 2010 Med/Surg addition are all located within one large smoke compartment. The Facility representative was unable to identify a smoke barrier within this area to comply with 18.3.7.1. Therefore, this area is a noncompliant smoke compartment due to the following:

a. A smoke compartment is required to divide every story having an occupant load of 50 or more persons into not less than two compartments to comply with 18.3.7.1 (2).

B. 08/21/2014 at 11:00am The facility representative was not able to identify the square footage of any smoke compartment within the facility to comply with the size limit in accordance with 18.3.7.1(3).

A. Based on an observation of hazardous areas the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

1. 08/21/2014 at 1:15pm Storage room within the E.D. adjacent to the E.M. work room lacks self closing door hardware.

2. 08/21/2014 at 1:35pm Clean supply room within the ED behind the nurse station lacks self closing door hardware.

3. 08/21/2014 at 2:10pm Chiller room lacks a self closing, fire resistant labeled door.

4. 08/21/2014 at 2:35pm I.T. room (referred to as computer room) lacks self closing door hardware.

5. 08/21/2014 at 2:45pm Staff Break room (located across the corridor from Receiving) door into the Vending machine room ( this room is designated storage on the Life Safety floor plans and contains items stored within) lacks self closing hardware.

6. 08/21/2014 at 3:00pm Respiratory Therapy Locker/Storage room lacks self closing door hardware on both doors. The door closer's were observed with missing main arm assemblies. The door to the patient care hallway was wedged open with a storage box.


B. 08/21/2014 at 2:45pm Wall between Staff Break Room and storage room (former kitchen) contains pipe penetration which are not sealed against the passage of smoke and fire to maintain the fire resistance rating of the wall. The location of the holes is in the west end of this wall.


C. 08/21/2014 at 2:05pm Wall between the Med/Gas storage room (located within the Chiller room) and the Surgery janitor closet contains holes and penetrations which are not sealed against the passage of smoke and fire to maintain the 1-hour fire resistance rating of the wall.


D. Rooms or areas currently being used for storage, not shown as designated hazardous areas on the facility Life Safety floor plan, are not protected to comply with 18.3.2.1. for areas forming a hazard greater than that of the normal occupancy. Example locations include:

1. 08/21/2014 at 2:20pm Respiratory Therapy room directly connected to means of egress corridor appears to be an exam room, however, surveyor observed that it is being used for storage. The doors lack self closing hardware.

a. This same room is not designated as hazardous on the Life Safety floor plan and is not enclosed with 1-hour fire resistant walls for storage rooms larger than 100 s.f.

2. 08/21/2014 at 2:23pm Pharmacy IV room surveyor observed that it is being used for storage. The corridor door lacks self closing hardware.

a. This same room is not designated as hazardous on the Life Safety floor plan and is not enclosed with 1-hour fire resistant walls for storage rooms larger than 100 s.f.

Based on random observation during the survey walk-through and document review the use of the suite concept does not comply with 18.2.5.2 - 2.5.8. During discussion with the Facility representative, the size, location and suite perimeters could not be confirmed. The lack of distinction between an aisle (allowed to contain items, may also have one direction of egress) or a corridor that contains two remote means of egress could prevent patients, staff and visitors from exiting an area of the building in a safe manner during a fire/smoke event.

Findings include:

A. 08/21/2014 at 11:00am the surveyor questioned the facility's use of suites to comply with 18.2.5. The surveyor was informed that the E.D., Surgery, and Pre-Op/Recovery are suites however the following was not confirmed by the facility:

1. The square foot size of any suites to comply with 18.2.5.2 and 2.5.3.

2. The available means of egress from any suite to a corridor to comply with 18.2.5.1.

3. The number and type (no hazardous areas) of any intervening rooms to comply with 18.2.5.5.

Based on random observation during the survey walk-through while accompanied by engineering staff, battery powered emergency illumination is not provided to comply with 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2 for locations of anesthetized patients. This deficiency could affect any patients, staff, or visitors on this floor level because the failure of the normal lighting could prevent them from safely exiting the building under fire conditions.

Findings include:


A. 08/21/2014 at 1:22PM Operating rooms were observed to not be provided with battery powered emergency lighting to comply with NFPA 99-1999, 3-3.2.1.2(a)5(e). During an interview held with the Facility representative. the surveyor was informed that the Operating Rooms contained ballasted battery backup emergency lighting. However, none of these are checked and tested to comply with NFPA 99. This same situation occurs in Pr-Op/Recovery and the E.D. Trauma room.

During the survey walk-through while accompanied by facility representatives, the surveyor observed paths of egress that were not identified by exit signage to comply with 18.2.10 and 7.10.2. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:

A. Exit routes are not clearly defined to comply with 18.2.10. Conditions observed include but are not necessarily limited to the following:

1. 08/21/2014 at 12:20pm Exit signage is not present in the Pre-Op, Recovery area that indicate an exit path to the nearest corridor to comply with 18.2.5.

2. 08/21/2014 at 2:15pm The exit sign at the corridor intersection adjacent to Lab and the north corridor leading to the Boiler room has a directional arrow with the indicated direction that is not appropriate and does not comply with 18.2.3.3 for corridor width requirements in a hospital.

3. 08/21/2014 at 1:50pm Exit signage to identify the 2nd available exit path in the O.R. corridor is not provided. Further, if this is a "suite" to comply with 18.2.5.2 or 18.2.5.3 then the second remotely located exit access is not designated.

Based on random observation during the survey walk-through accompanied by the Head of Maintenance, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

The finding is:

A. 08/22/2014 at 9:30am The fire shutter for the Pharmacy pass-through window did not close upon activation of the fire alarm under either detector activations or pull station activation.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 18.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1.
These deficiencies could affect any patients, staff, or visitors in the immediate area by preventing the timely activation of the sprinkler heads.

Findings include:

A. 3:00pm 08/21/2014: Electrical Closet (within the 2010 MedSurg building addition between room numbers 306 and 307) was observed to lack sprinkler protection to comply NFPA 13 1999 5-6.4.1.1.

B. 3:30pm 08/21/2014 Receiving area located adjacent to the Boiler room contains sprinkler piping that lacks bracing spaced to comply with NFPA 13.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99 1999, 8-3.1.11.2(c)(2). These deficiencies could affect any patients, staff, or visitors in the immediate area because the oxygen could contribute to an ongoing fire.

Findings include:

A. Oxygen tanks stored in sprinklered areas are not separated by minimum 5'-0" from combustibles. Locations observed include but are not necessarily limited to the following:

1. 08/21/2014 2:25pm at Storage room within Respiratory Care (observed 13 tanks) less than 5'-0" from combustible cardboard boxes and plastics.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's emergency electrical system are tested in accordance with NFPA 110 1999. Failure to test and document operating parameters for comparison to previous readings can cause an impending failure of the system to go un-noticed.

Findings include;

A. 08/22/2014 at 10:15am During the document review process, it was determined that the only available documentation of the weekly emergency generator inspection was a written log of the weeks. There is no written record of which components for the emergency generator were visually inspected each week to comply with NFPA 110 1999 6-4.1.