HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain the Gym door so it positively latched when self-closed. This condition would allow smoke to migrate into the exit corridor.
Findings are:
Observation on 6/27/16, at 2:09 pm, revealed the West Interior Gym door failed to positively latch when self-closed.
In an interview on, 6/27/16, at 2:09 pm, Safety A acknowledged that the door failed to latch.

Based on observation and staff interview, the facility failed to post an exit sign so the way to reach a second exit from the Youth Unit was apparent to occupants. This condition would prevent occupants from identifying a second exit during a fire.
Findings are:
Observation on 6/27/16, at 2:26 pm, revealed an exit sign to direct occupants to the second exit from the corridor by the Lower Level elevator while looking south from the Youth Unit failed to be visible.
In an interview on 6/27/16, at 2:26 pm, Safety A acknowledged an exit sign was not visible in two separate directions.

Based on observation and staff interview, the facility failed to provide a stable walking surface to a public way from all required exterior exits. This condition had the potential to prevent staff from exiting the facility.
Findings are:
Observation on 6/27/16, at 11:58 am, revealed a sidewalk or other stable walking surface failed to be provided outside of each required exit to a public way.
In an interview on 6/27/16, at 11:58 am, Safety A confirmed that not all exterior doors marked with exit signs had sidewalks or a stable walking surface that connected to a public way.
Official Interpretation 96-02

Based on observation and staff interview, the facility failed to maintain a battery backup emergency light. This condition had the potential to leave occupants in darkness during loss of power.
Findings are:
Observation on 6/27/16, at 2:12 pm, revealed battery backup emergency light L1 failed to function when tested.
In an interview on 6/27/16, at 2:12 pm, Safety A acknowledged the findings.
2000, NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to conduct fire drills for all shifts under varying conditions. This condition did not provide simulated training for staff to respond to a fire emergency.
Findings are:
Record review on 6/27/16, at 1:04 pm, revealed fire drills failed to have at least one hour difference between each quarter for the past year for the following shifts:
2nd Shift: 11/19/15 at 3:00 pm, 9/30/15 at 7:35 pm, 6/28/15 at 4:00 pm, and 3/23/15 at 4:30 pm.
3rd Shift: 9/29/15 at 11:05 pm, 6/26/15 at 12:04 pm, and 2/19/15 at 11:16 pm.
In an interview on 6/27/16, at 1:04 pm, Safety A acknowledged the findings.

Based on record review and staff interview, the facility failed to have a required load bank test conducted for the emergency generator annually. This condition increased the potential that the generator would fail to run during loss of power.
Findings are:
Record review on 6/27/16, at 1:23 pm, revealed the two most recent load bank test reports were dated 3/2/15 and 5/17/16. The load bank test failed to be conducted annually.
In an interview on 6/27/16, at 1:23 pm, Safety A confirmed that the required load bank test failed to be conducted within a year from the last test.
NFPA 110, 6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on observation and staff interview, the facility failed to use electrical equipment as Underwriter Laboratory listed and failed to protect energized electrical wiring from contact and/or damage. This condition created the potential of an electrical fire.
Findings are:
Observation on 6/27/16, from 11:47 am to 2:31 pm revealed:
1. An open electrical junction box in the Generator Room above Panel LA failed to have a cover installed on the box.
2. A microwave was plugged into a power strip in the Environmental Services room. The heat-producing appliance failed to be plugged directly into a wall outlet.
3. The power cord for the battery backup emergency light in the Pharmacy Back Hallway was installed through the suspended ceiling tile to an outlet above the ceiling. The light failed to be plugged in so that it was not necessary to install the cord through the ceiling.
4. Power strips in the Security Camera Room were daisy chained into a battery backup power strip. The power strips failed to be plugged directly into a wall outlet.
5. A toaster was plugged into a power strip in the Youth Break Room. The heat-producing appliance failed to be plugged directly into a wall outlet.
In an interview on 6/27/16, from 11:47 am to 2:31 pm, Safety A confirmed the use of the electrical equipment.

Based on observation and staff interview, the facility failed to maintain the Gym door so it positively latched when self-closed. This condition would allow smoke to migrate into the exit corridor.
Findings are:
Observation on 6/27/16, at 2:09 pm, revealed the West Interior Gym door failed to positively latch when self-closed.
In an interview on, 6/27/16, at 2:09 pm, Safety A acknowledged that the door failed to latch.

Based on observation and staff interview, the facility failed to post an exit sign so the way to reach a second exit from the Youth Unit was apparent to occupants. This condition would prevent occupants from identifying a second exit during a fire.
Findings are:
Observation on 6/27/16, at 2:26 pm, revealed an exit sign to direct occupants to the second exit from the corridor by the Lower Level elevator while looking south from the Youth Unit failed to be visible.
In an interview on 6/27/16, at 2:26 pm, Safety A acknowledged an exit sign was not visible in two separate directions.

Based on observation and staff interview, the facility failed to provide a stable walking surface to a public way from all required exterior exits. This condition had the potential to prevent staff from exiting the facility.
Findings are:
Observation on 6/27/16, at 11:58 am, revealed a sidewalk or other stable walking surface failed to be provided outside of each required exit to a public way.
In an interview on 6/27/16, at 11:58 am, Safety A confirmed that not all exterior doors marked with exit signs had sidewalks or a stable walking surface that connected to a public way.
Official Interpretation 96-02

Based on observation and staff interview, the facility failed to maintain a battery backup emergency light. This condition had the potential to leave occupants in darkness during loss of power.
Findings are:
Observation on 6/27/16, at 2:12 pm, revealed battery backup emergency light L1 failed to function when tested.
In an interview on 6/27/16, at 2:12 pm, Safety A acknowledged the findings.
2000, NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to conduct fire drills for all shifts under varying conditions. This condition did not provide simulated training for staff to respond to a fire emergency.
Findings are:
Record review on 6/27/16, at 1:04 pm, revealed fire drills failed to have at least one hour difference between each quarter for the past year for the following shifts:
2nd Shift: 11/19/15 at 3:00 pm, 9/30/15 at 7:35 pm, 6/28/15 at 4:00 pm, and 3/23/15 at 4:30 pm.
3rd Shift: 9/29/15 at 11:05 pm, 6/26/15 at 12:04 pm, and 2/19/15 at 11:16 pm.
In an interview on 6/27/16, at 1:04 pm, Safety A acknowledged the findings.

Based on record review and staff interview, the facility failed to have a required load bank test conducted for the emergency generator annually. This condition increased the potential that the generator would fail to run during loss of power.
Findings are:
Record review on 6/27/16, at 1:23 pm, revealed the two most recent load bank test reports were dated 3/2/15 and 5/17/16. The load bank test failed to be conducted annually.
In an interview on 6/27/16, at 1:23 pm, Safety A confirmed that the required load bank test failed to be conducted within a year from the last test.
NFPA 110, 6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on observation and staff interview, the facility failed to use electrical equipment as Underwriter Laboratory listed and failed to protect energized electrical wiring from contact and/or damage. This condition created the potential of an electrical fire.
Findings are:
Observation on 6/27/16, from 11:47 am to 2:31 pm revealed:
1. An open electrical junction box in the Generator Room above Panel LA failed to have a cover installed on the box.
2. A microwave was plugged into a power strip in the Environmental Services room. The heat-producing appliance failed to be plugged directly into a wall outlet.
3. The power cord for the battery backup emergency light in the Pharmacy Back Hallway was installed through the suspended ceiling tile to an outlet above the ceiling. The light failed to be plugged in so that it was not necessary to install the cord through the ceiling.
4. Power strips in the Security Camera Room were daisy chained into a battery backup power strip. The power strips failed to be plugged directly into a wall outlet.
5. A toaster was plugged into a power strip in the Youth Break Room. The heat-producing appliance failed to be plugged directly into a wall outlet.
In an interview on 6/27/16, from 11:47 am to 2:31 pm, Safety A confirmed the use of the electrical equipment.