HospitalInspections.org

Based on observation and interview, the facility does not maintain fire separations related to corridor doors and hazardous areas in compliance with NFPA 101 Life Safety Code, as evidenced for the fire doors adjacent to the first floor children's unit nurse's station.

Findings include:

Observation during tour on 5/27/15 from 2:30PM to 3:00PM revealed the fire doors adjacent to the first floor children's unit nurse's station did not close tightly as required by this regulation.

This finding was verified with VP (Vice President) Patient Care Services RN (Registered Nurse) Staff #1 on 5/27/15.

Based on observation and interview, the facility does not maintain fire rated separations related to hazardous areas in compliance with NFPA 101 Life Safety Code, as evidenced for the soiled utility rooms on floors 2-4, and the 4th floor clean linen room.

Findings include:

Observation of soiled utility rooms on 5/27/15 between the hours of 2:00PM and 3:30PM on floors 2, 3 and 4 revealed penetrations in the one hour rated walls, and the absence of door closers.

Observation on 5/27/15 at 2:15PM of the clean linen room on the 4th floor revealed the door has been removed from the room.

These findings were verified with VP Patient Care Services RN Staff #1 on 5/27/15.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 8/11/11.

Based on document review and interview, the facility does not conduct quarterly fire drills on each shift as required by this regulation, as evidenced for 2015.

Findings include:

Review on 5/28/15 at 10:00AM of the facility's 2015 fire drill logs revealed fire drills were only conducted during the day shift. This regulation requires quarterly drills on each shift to ensure all staff are trained annually.

This finding was verified with Director of Plant Operations Staff #2 on 5/28/15.

Based on observation and interview, the facility does not maintain fire safety in the exit access corridors related to storage of surplus furniture.

Findings include:

Observation during tours on 5/26/15 and 5/27/15 revealed surplus beds, desks, mattresses and other furniture stored in the corridors on floors 2 and 4.

This finding was verified with Director of Plant Operations Staff #2 on 5/27/15.

Based on observation and interview, the facility does not provide fire safety to patients and staff related to storage of combustible materials in non-protected areas, as evidenced for corridors on 4 of 4 floors.

Findings include:

Observation during tours on 5/26/15 and 5/27/15 revealed numerous 96 gallon medical record waste containers stored in the corridors on four of four floors. This regulation requires containers of waste greater than 32 gallons be stored in protected rooms of one-hour fire rating or sprinklered.

This finding was verified with Director of Plant Operations Staff #2 on 5/27/15.

Based on observation and interview, the facility does not store flammable materials in a flammable material cabinet as required by this regulation.

Findings include:

Observation during tour on 5/28/15 at 2:10PM revealed paints, cleaners and aerosol cans stored in the facility's shop in a metal cabinet. This cabinet was not an approved flammable storage cabinet.

This finding was confirmed with Director of Plant Operations Staff #2 on 5/28/15.

Based on observation and interview, the facility does not maintain fire separations related to corridor doors and hazardous areas in compliance with NFPA 101 Life Safety Code, as evidenced for the fire doors adjacent to the first floor children's unit nurse's station.

Findings include:

Observation during tour on 5/27/15 from 2:30PM to 3:00PM revealed the fire doors adjacent to the first floor children's unit nurse's station did not close tightly as required by this regulation.

This finding was verified with VP (Vice President) Patient Care Services RN (Registered Nurse) Staff #1 on 5/27/15.

Based on observation and interview, the facility does not maintain fire rated separations related to hazardous areas in compliance with NFPA 101 Life Safety Code, as evidenced for the soiled utility rooms on floors 2-4, and the 4th floor clean linen room.

Findings include:

Observation of soiled utility rooms on 5/27/15 between the hours of 2:00PM and 3:30PM on floors 2, 3 and 4 revealed penetrations in the one hour rated walls, and the absence of door closers.

Observation on 5/27/15 at 2:15PM of the clean linen room on the 4th floor revealed the door has been removed from the room.

These findings were verified with VP Patient Care Services RN Staff #1 on 5/27/15.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 8/11/11.

Based on document review and interview, the facility does not conduct quarterly fire drills on each shift as required by this regulation, as evidenced for 2015.

Findings include:

Review on 5/28/15 at 10:00AM of the facility's 2015 fire drill logs revealed fire drills were only conducted during the day shift. This regulation requires quarterly drills on each shift to ensure all staff are trained annually.

This finding was verified with Director of Plant Operations Staff #2 on 5/28/15.

Based on observation and interview, the facility does not maintain fire safety in the exit access corridors related to storage of surplus furniture.

Findings include:

Observation during tours on 5/26/15 and 5/27/15 revealed surplus beds, desks, mattresses and other furniture stored in the corridors on floors 2 and 4.

This finding was verified with Director of Plant Operations Staff #2 on 5/27/15.

Based on observation and interview, the facility does not provide fire safety to patients and staff related to storage of combustible materials in non-protected areas, as evidenced for corridors on 4 of 4 floors.

Findings include:

Observation during tours on 5/26/15 and 5/27/15 revealed numerous 96 gallon medical record waste containers stored in the corridors on four of four floors. This regulation requires containers of waste greater than 32 gallons be stored in protected rooms of one-hour fire rating or sprinklered.

This finding was verified with Director of Plant Operations Staff #2 on 5/27/15.

Based on observation and interview, the facility does not store flammable materials in a flammable material cabinet as required by this regulation.

Findings include:

Observation during tour on 5/28/15 at 2:10PM revealed paints, cleaners and aerosol cans stored in the facility's shop in a metal cabinet. This cabinet was not an approved flammable storage cabinet.

This finding was confirmed with Director of Plant Operations Staff #2 on 5/28/15.