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Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. and Chapter 7, Section 7.2. In a fire emergency, this deficient practice could adversely affect any patients, staff or visitors within the affected smoke compartment.

FINDINGS INCLUDE:

On 06/19/2014 at 1:40 PM, observation revealed the corridor door to the Administrative Assistant's Office did not positively latch into the door frame, because the door was not equipped with positive latching hardware. Rather, the door was equipped with a single-key deadbolt lock, with a thumb-turn device on the egress side.

This finding was verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to provide battery-powered emergency lighting at an anesthetizing location, and was not in conformance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999). In the event of a building power failure, this deficient practice could adversely affect the safety of an anesthetized patient and all staff within the affected area.

FINDINGS INCLUDE:

On 06/19/2014 at 11:50 AM, while surveying in the operating room (OR), observation revealed that no battery-powered emergency lighting was provided at the anesthetizing location. This arrangement was not in accordance with the requirements at NFPA 99 (1999 edition) Chapter 3, Section 3-3.2.1.2 (5)(e).

This finding was verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. and Chapter 7, Section 7.2. In a fire emergency, this deficient practice could adversely affect any patients, staff or visitors within the affected smoke compartment.

FINDINGS INCLUDE:

On 06/19/2014 at 1:40 PM, observation revealed the corridor door to the Administrative Assistant's Office did not positively latch into the door frame, because the door was not equipped with positive latching hardware. Rather, the door was equipped with a single-key deadbolt lock, with a thumb-turn device on the egress side.

This finding was verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to provide battery-powered emergency lighting at an anesthetizing location, and was not in conformance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999). In the event of a building power failure, this deficient practice could adversely affect the safety of an anesthetized patient and all staff within the affected area.

FINDINGS INCLUDE:

On 06/19/2014 at 11:50 AM, while surveying in the operating room (OR), observation revealed that no battery-powered emergency lighting was provided at the anesthetizing location. This arrangement was not in accordance with the requirements at NFPA 99 (1999 edition) Chapter 3, Section 3-3.2.1.2 (5)(e).

This finding was verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to maintain the emergency generator in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.1.3 and NFPA 110 (1999) Chapter 6, Section 6-4. In a fire or other emergency, this deficient practice could adversely affect 15 of 15 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/19/2014 at 11:15 AM, during a review of the emergency generator monthly inspection and testing logs for the previous year, the percent of load (KW) had not been recorded. As such, it could not be documented that the genset had been either:
1). Exercised at not less than 30% of the EPS nameplate rating, or;
2). Loaded to maintain the minimum exhaust gas temperature as recommended by the manufacturer, or;
3). Had a 2-hour load bank test performed within the previous year.

This finding was confirmed with the chief building engineer.