HospitalInspections.org

Based on observation and interview, the provider failed to maintain the two hour fire-resistive wall between the clinic and the hospital in two randomly observed locations (north exit from the provider-based clinic and at the nurses station for the clinic). Findings include:

1. Observation at 2:08 p.m. on 1/21/15 revealed three insulated water pipes penetrating the two hour wall above the lay-in ceiling at the north door from the provider-based clinic to the hospital. There were unsealed openings around the penetrations. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

2. Observation at 2:14 p.m. on 1/21/15 revealed one electrical conduit with two category 5 computer cables penetrating the two hour wall between the provider-based clinic and the hospital. The penetration had an unsealed opening around the conduit above the lay-in ceiling in the north wall of the clinic nurses station. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The penetrations affected one of several required components of fire-resistive separation wall characteristics.

Based on observation and interview, the provider failed to maintain the two hour fire-resistive wall between the hospital and the clinic in two randomly observed locations (north entrance to the provider-based clinic and at the nurses station for the clinic). Findings include:

1. Observation at 2:08 p.m. on 1/21/15 revealed three insulated water pipes penetrating the two hour wall above the lay-in ceiling at the north door to the provider-based clinic from the hospital. There were unsealed openings around the penetrations. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

2. Observation at 2:14 p.m. on 1/21/15 revealed one electrical conduit with two category 5 computer cables penetrating the two hour wall between the provider-based clinic and the hospital. The penetration had an unsealed opening around the conduit above the lay-in ceiling in the north wall of the clinic nurses station. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The penetrations affected one of several required components of fire-resistive separation wall characteristics.

Based on observation, testing, and interview, the provider failed to ensure exits were readily accessible at all times. Three of five exit doors (north to the long-term care, north to the exterior of the building, and east out of the provider-based clinic) were equipped with magnetic door locks that were not delayed egress type. Findings include:

1. Observation and interview beginning at 11:50 a.m. on 1/21/15 revealed the exit doors in the north wall to the long-term care, the exit doors north to the exterior of the building by the mechanical room, and the exit door in the east wall of the provider-based clinic were equipped with magnetic locks. The doors were equipped with panic bars, but could only be opened from the inside to egress (when locked) with a push button mounted in close proximity to the door. The doors were not equipped with a sensor on the egress side arranged to detect an occupant approaching the door which would unlock the door. Testing of the locked doors at the time of the observation (without using the push button releases) revealed the magnetically locked doors were not equipped with delayed egress type magnetic locks. Interview with the administrator at 3:30 p.m. revealed the provider also had a lockdown policy which interrupted the function of the push button releases. He was unaware the magnetic locks were not in compliance with egress requirements.

This deficiency has the potential to affect 100 percent of the occupants of the building in an emergency egress situation.

Based on observation and interview, the provider failed to install a remote shutoff switch for the generator. Findings include:

1. Observation at 3:17 p.m. on 1/21/15 revealed the generator for the critical access hospital was situated on the exterior of the building near the northwest corner and was not equipped with a remote shut off. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency affected one of numerous generator installation requirements.

Based on observation and interview, the provider failed to maintain the two hour fire-resistive wall between the clinic and the hospital in two randomly observed locations (north exit from the provider-based clinic and at the nurses station for the clinic). Findings include:

1. Observation at 2:08 p.m. on 1/21/15 revealed three insulated water pipes penetrating the two hour wall above the lay-in ceiling at the north door from the provider-based clinic to the hospital. There were unsealed openings around the penetrations. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

2. Observation at 2:14 p.m. on 1/21/15 revealed one electrical conduit with two category 5 computer cables penetrating the two hour wall between the provider-based clinic and the hospital. The penetration had an unsealed opening around the conduit above the lay-in ceiling in the north wall of the clinic nurses station. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The penetrations affected one of several required components of fire-resistive separation wall characteristics.

Based on observation and interview, the provider failed to maintain the two hour fire-resistive wall between the hospital and the clinic in two randomly observed locations (north entrance to the provider-based clinic and at the nurses station for the clinic). Findings include:

1. Observation at 2:08 p.m. on 1/21/15 revealed three insulated water pipes penetrating the two hour wall above the lay-in ceiling at the north door to the provider-based clinic from the hospital. There were unsealed openings around the penetrations. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

2. Observation at 2:14 p.m. on 1/21/15 revealed one electrical conduit with two category 5 computer cables penetrating the two hour wall between the provider-based clinic and the hospital. The penetration had an unsealed opening around the conduit above the lay-in ceiling in the north wall of the clinic nurses station. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The penetrations affected one of several required components of fire-resistive separation wall characteristics.

Based on observation, testing, and interview, the provider failed to ensure exits were readily accessible at all times. Three of five exit doors (north to the long-term care, north to the exterior of the building, and east out of the provider-based clinic) were equipped with magnetic door locks that were not delayed egress type. Findings include:

1. Observation and interview beginning at 11:50 a.m. on 1/21/15 revealed the exit doors in the north wall to the long-term care, the exit doors north to the exterior of the building by the mechanical room, and the exit door in the east wall of the provider-based clinic were equipped with magnetic locks. The doors were equipped with panic bars, but could only be opened from the inside to egress (when locked) with a push button mounted in close proximity to the door. The doors were not equipped with a sensor on the egress side arranged to detect an occupant approaching the door which would unlock the door. Testing of the locked doors at the time of the observation (without using the push button releases) revealed the magnetically locked doors were not equipped with delayed egress type magnetic locks. Interview with the administrator at 3:30 p.m. revealed the provider also had a lockdown policy which interrupted the function of the push button releases. He was unaware the magnetic locks were not in compliance with egress requirements.

This deficiency has the potential to affect 100 percent of the occupants of the building in an emergency egress situation.

Based on observation and interview, the provider failed to install a remote shutoff switch for the generator. Findings include:

1. Observation at 3:17 p.m. on 1/21/15 revealed the generator for the critical access hospital was situated on the exterior of the building near the northwest corner and was not equipped with a remote shut off. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency affected one of numerous generator installation requirements.