HospitalInspections.org

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with a complete automatic fire sprinkler system. Findings include:

1. Observation on 7/12/16 at 11:05 a.m. revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey conducted on 3/21/12 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. One randomly observed corridor door was held in the open position by an unapproved device. The door to the x-ray/radiology room was held open. Findings include:

1. Observation at 11:30 a.m. on 7/12/16 revealed the south corridor door to the x-ray/radiology was held in the open position with a rubber wedge. That device was an impediment to closing the door in an emergency. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency had the potential to affect 100% of the occupants in that smoke compartment.

Based on observation, interview, and record review, the provider failed to install a paved path of exit discharge to the public way at one exit (south exit stair enclosure) of the building. Findings include:

1. Observation at 11:30 a.m. on 7/12/16 revealed the exit from the south exit stair enclosure had a landing that ended approximately 100 feet from the nearest street. Interview with the maintenance supervisor at the time of the observation confirmed that condition. The maintenance supervisor also stated he believed the facility had always been that way. Review of the previous survey conducted on 3/21/12 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation and interview, the provider failed to provide adequate training for staff regarding fire drill procedures. Findings include:

1. Observation at 2:00 p.m. on 7/12/16 of the fire drill revealed the following corridor doors were not shut:
*Radiology (held open with a rubber floor wedge).
*The door to the CT area (a rubber-backed rug was on the floor across the threshold of the door and prevented the door from self-closing).
*The new CT room door was not shut.

Continued observation revealed the staff that responded to the simulated fire (drill) were uncertain of the proper procedure to follow for the drill and had to be prompted (by the maintenance supervisor) to complete the process. Interview with the maintenance supervisor at the time of the observation revealed the majority of the responding staff had been working at the hospital less than one year.

This deficiency could potentially affect 100% of the building's occupants.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building must be equipped with a complete automatic sprinkler system. Findings include:

1. Observation on 7/12/16 at 11:00 a.m. revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey conducted on 3/21/12 confirmed that finding.

The building meets the FSES. Please mark and "F" in the completion date column (X5).

Based on observation and interview, the provider failed to install emergency power circuit receptacles in the patient corridor. Two of two red (denoting emergency outlets) emergency 110 volt outlets had an outdated plug configuration. Findings include:

1. Observation at 2:15 p.m. on 7/12/16 revealed two emergency power circuit receptacles were installed in the patient wing. The receptacles were an older style outlet for twist-lock plugs. Interview with the Chief Executive Officer at 2:30 p.m. on 7/12/16 revealed the provider did not have equipment with those type of plug-ins for use in the patient wing. It was unknown when the equipment change had occurred.

The deficiency had the potential to affect 100% of the patients in that smoke compartment.