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Based on observation and staff interview, the facility failed to maintain exits in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain exits as required could delay egress resulting in injury or death during an emergency. The deficiency affected approximately 33 percent of the exits, as well as the 10 patients and staff. The findings were:

Observation on 5/16/2018 at 11:20 AM at the main entrance revealed a dead bolt lock on the door. Further observation revealed that the lock could not be easily distinguished as locked or unlocked. Additionally, the door was missing a visible sign that stated the door was to remain unlocked when the building was occupied.

Interview with the facility manager at the time of the observation acknowledged the lock and missing sign, and indicated she was unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.2.2.2.2; 7.2.1.5.5.1(2)(3)
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Based on observation and staff interview, the facility failed to provide exit access in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide exit access as required could delay egress resulting in injury or death during an emergency. The deficiency affected approximately 33 percent of all exit discharge locations, as well as the 5 patients and staff. The findings were:

Observation on 5/16/2018 at 10:40 AM at the west exit discharge revealed the sidewalk from the exit did not provide direct access to the public way. Access to the public way required crossing the adjacent field.

Interview with the head nurse at the time of the observation acknowledged the sidewalk did not terminate at the public way, and indicated she was unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.2.7: 7.7.1

Based on observation and staff interview, the facility failed to maintain exit stairwells in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain exit stairwells as required may result in injury or death during an emergency. The deficiency affected two (2) of four (4) exit stairwells. The findings were:

Observation on 5/15/2018 at 2:18 PM located at the east exit stairs that connect three floors and at the west exit stairwell of the addition from 2011 revealed that both locations had storage located within the stairwell. The east exit stairwell that connects three floors adjacent to the radiology exit revealed a hospital gurney recessed in an alcove within the stairwell. The west exit stairwell from the 2011 addition located adjacent to the elevator equipment room revealed storage of lighting fixture covers.

Interview with the facility maintenance staff at the time of the observation acknowledged the storage, and indicated they were unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 7.2.2.5.3
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Based on observation and staff interview, the facility failed to provide handrails at exit discharge stairs in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide handrails at exit discharge stairs as required may result in injury or death due to a fall. The deficiency affected two (2) of eight (8) exits. The findings were:

Observation on 5/15/2018 at 11:03 AM located on the first floor northwest exit discharge and west exit discharge revealed stairs that had multiple risers. Further observation revealed that the stairs did not have handrails.

Interview with the facility maintenance staff at the time of the observation acknowledged the lack of handrails, and indicated they were unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.7; 7.7; 7.2.2.4.1.1

Based on observation and staff interview, the facility failed to provide handrails at ramps in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide handrails for ramps as required may result in injury or death due to a fall. The deficiency affected one (1) of eight (8) exit discharges. The findings were:

Observation on 5/15/2018 at 2:16 PM located at the southeast exit revealed two ramps with no handrails on either side. Further observation revealed that each ramp had a rise greater than 6 inches. Slope of the surface exceeded 1:20 classifying the surface as a ramp.

Interview with the facility maintenance staff at the time of the observation acknowledged the lack of handrails, and indicated they were unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 7.2.2.4
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Based on observation and staff interview, the facility failed to maintain emergency lighting in accordance with the 2012 Life Safety Code. Failure to maintain emergency lighting as required could delay egress resulting in injury or death. The deficiency affected approximately 25 percent of the emergency lighting in the facility, as well as the 5 patients and staff. The findings were:

Observation on 05/16/2018 at 10:26 AM adjacent to the front entrance revealed that the emergency lighting failed to operate when tested.

Interview with the head nurse at the time of the observation acknowledged the emergency lighting failed to operate, and indicated she was unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.2.9.1; 7.9.3.1.1
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Based on observation and staff interview, the facility failed to provide exit signs in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide exit signs as required could delay egress resulting in injury or death in an emergency. The deficiency affected approximately 20 percent of exit locations. The findings were:

Observation on 5/15/2018 at 10:18 AM located in the Post Anesthesia Care Unit (PACU) of the facility revealed that the suite had two main exits. Further observation revealed that only one of the two main exits was equipped with an exit sign.

Interview with the facility maintenance staff at the time of the observation acknowledged the missing exit sign, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.10.1; 7.10.12.2
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Based on observation and staff interview, the facility failed to provide protection against hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide protection against hazardous areas may lead to injury or death due to a fire. The deficiency affected one (1) of three (3) doors in hazardous areas. The findings were:

Observation on 5/15/2018 at 11:31 AM located in the medical records office revealed a large amount of combustible material. Further observation revealed that an adjacent room was repurposed for overflow from the medical records room. The overflow room revealed a door that goes directly into the corridor and was not equipped with an automatic or self-closing device.

Interview with the facility maintenance staff at the time of the observation acknowledged the lack of an automatic or self-closing device, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA, Section: 19.3.2.1.3
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Based on document review and staff interview, the facility failed to maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain fire alarm systems as required could allow system failure resulting in injury or death. The deficiency affected one (1) of one (1) systems, as well as 180 patients and staff. The findings were:

Document review on 5/16/2018 at 12:00 PM revealed the facility could not verify that the fire alarm system had been tested during the previous 12 months. The last time the system had been tested was in March 2017.

Interview with the facility maintenance staff at the time of the observation acknowledged the lack of testing, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.3.5.3; 9.7.5
2010 NFPA 72, Section: Table 14.4.5
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Based on observation and staff interview, the facility failed to maintain fire sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to maintain fire sprinkler systems as required could result in injury or death during an emergency. The deficiency affected one (1) of one (1) fire sprinkler systems, as well as the 10 patients and staff. The findings were:

Observation on 5/16/2018 at 11:05 AM in the janitor's closet revealed a fire sprinkler system riser. Further observation revealed that the fire sprinkler system was last tested in 2015.

Interview with the facility manager at the time of the observation acknowledged that the fire system had not been tested since 2015, and indicated she was unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.3.4.2(3); 9.7.5
2011 NFPA 25, Section: Table 5.1.1.2
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Based on observation and staff interview, the facility failed to inspect and maintain portable fire extinguishers in accordance with 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 10, Standard for Portable Fire Extinguishers. Failure to maintain portable fire extinguishers as required could result in injury or death during an emergency. The deficiency affected approximately 50 percent of the fire extinguishers in the facility, as well as the 5 patients and staff. The findings were:

Observation on 5/16/2017 at 10:26 AM revealed a fire extinguisher adjacent to the main entrance had not received its monthly inspection during March and April 2018. Further observation revealed a second fire extinguisher in the hallway had also not been inspected during March and April 2018.

Interview with the head nurse at time of the observation acknowledged the fire extinguishers had not been signed off, and indicated she was unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 39.3.5; 9.7.4.1
2010 NFPA 10, Section 6.3.1

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. Failure to maintain corridor doors as required could allow fire and smoke spread resulting in injury or death. The deficiency affected approximately 10 percent of the corridor doors in the facility, as well as the 180 patients and staff. The findings were:

1. Observation on 5/15/2018 at 12:30 PM on the 1st floor adjacent to Mammography revealed a set of fire doors that failed to close completely when tested.

Interview with the facility maintenance supervisor at the time of the observation acknowledged the doors failed to close, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 8.3.3.3
2010 NFPA 80, Section: 5.2.4.2(6)

2. Observation on 5/15/2018 at 2:25 PM adjacent to Physical Therapy revealed a set of fire doors that lacked fire door hardware.

Interview with facility maintenance staff at the time of the observation acknowledged the missing fire door hardware, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 8.3.3.1
2010 NFPA 80, Section: 7.4.3

3. Observation on 5/15/2018 at 2:20 PM on the 2nd floor revealed two sets of smoke compartment cross-corridor doors that when tested failed to close completely. Further observation revealed that when the doors were manually forced closed they had an approximate 1" gap between the doors.

Interview with facility maintenance staff at the time of the observation acknowledged the doors failed to close and the gap between the doors, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 7.2.1.8
2010 NFPA 80, Section: 6.3.1.7.1
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Based on document review and staff interview, the facility failed to conduct fire drills in accordance with the 2012 NFPA 101, Life Safety Code. Failure to conduct fire drills as required could delay egress resulting in injury or death. The deficiency affected 100 percent of the facility, as well as the 180 patients and staff. The findings were:

Document review on 5/16/2018 at 12:00 PM revealed that the facility failed to conduct required fire drills during the first quarter of 2018. The last fire drill was conducted in December 2017.

Interview with the facility maintenance staff at the time of the observation acknowledged the lack of fire drills, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 19.7.1.6
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Based on document review and staff interview, the facility failed to maintain electrical equipment in accordance with the 2012 NFPA 99, Health Care Facilities Code, and the 2010 NFPA 110, Standard for Emergency and Standby Power Systems . Failure to maintain electrical systems as required could cause injury or death during an emergency. The deficiency affected one (1) of one (1) systems, as well as the 180 patients and staff. The findings were:

Document review on 5/16/2018 at 12:00 PM revealed that the facility could not verify that the emergency generator had been load bank tested during the previous 12 months. The last annual test on the emergency generator was conducted during March 2017. Further observation revealed the facility could not verify that weekly and monthly checks of the generator had been conducted during 2018.

Interview with the facility maintenance staff at the time of the observation acknowledged the lack of generator testing, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 99, Section: 6.4.4.1.1.4
2010 NFPA 110, Sections: 8.3; 8.4
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