HospitalInspections.org

Based on observation and interview, the provider failed to ensure exit egress doors were maintained and accessible at two of six exits from the physician clinic (north and south exit from the waiting area). Findings include:

1. Observation at 4:00 p.m. on 1/31/17 revealed an exit door on the north side of the waiting room. That door was equipped with a keyed dead bolt lock set. A keyed lock shall only be permitted on the principal entrance only. That exit would not be considered a principal entrance and should not have been a keyed lock.

Interview with the facility director at the time of the above observation confirmed that condition. He indicated the south exit door from the waiting room also had the keyed lockset. He further indicated he was unaware those exit doors could not be equipped with a keyed lockset.

This deficiency has the potential to affect all occupants.

Based on observation and interview, the provider failed to ensure exit egress doors were maintained and accessible at all times at one of numerous exit egress doors (south egress door from the emergency department [ED] suite). Findings include:

1. Observation at 1:45 p.m. on 1/31/17 in the emergency department non-sleeping hospital patient suite revealed an exit egress door on the south side of that suite. That door provided egress from the suite into an exit corridor leading to the exterior. That door was equipped with a keyed deadbolt lockset. That lockset would require the use of a key to allow egress.

Interview with the facility director at the time of the above observation confirmed that condition. He indicated he was unsure why that keyed deadbolt lockset was installed on that door. He further indicated the panic hardware installed on that door would provide the needed security to limit unauthorized occupants from entering the ED suite while still providing exit egress out of the suite.

This deficiency has the potential to affect all patients and staff in the ED suite.

Based on observation and interview, the provider failed to ensure adequate illumination of exit egress was available at one of numerous exit egresses (exit discharge out of same day surgery department). Findings include:

1. Observation at 2:30 p.m. on 1/31/17 revealed an exit on the south side of the building out of the same day surgery department. Further observation of the exit discharge revealed a single bulb light fixture provided the only egress illumination. Redundant lighting shall be available such that failure of a single light shall not leave the exit discharge in less than adequate light level.

Interview with the facility director at the time of the above observation confirmed that condition. He indicated he was not aware that adequate exit discharge lighting was not available.

This deficiency has the potential to affect all occupants exiting from the same day surgery department.

Based on observation, record review, and interview, the provider failed to the ensure the automatic fire sprinkler system was tested, inspected, and maintained in accordance with NFPA 25 at three of numerous maintenance and testing requirements (post indicator valve not locked or supervised, no record of five year internal obstruction investigation, and fire department connection not readably accessible). Findings include:

1. Record review at 10:00 a.m. on 1/31/17 of the fire sprinkler system inspection reports prepared by Building Sprinkler Inc. revealed no indication of when the last five year internal obstruction investigation had been conducted. Every five years an obstruction investigation shall be conducted on the sprinkler apparatus. The investigation is to be conducted to ensure limited presence of foreign matter or obstructions within the sprinkler. The presence of obstructions or foreign matter may otherwise jeopardize the functionality of the fire sprinkler system.

2. Observation at 1:00 p.m. on 1/31/17 revealed a post-indicator valve at the northwest corner of the building. That valve was the primary shutoff valve for the fire sprinkler system. That valve should have been equipped with a lock or electronic valve supervision to ensure that valve was not tampered with. That valve was not provided with supervision and was not equipped with a lock.

3. Observation at 1:10 p.m. on 1/31/17 revealed a fire department connection (FDC) valve located near the post-indicator valve. Testing of the accessibility of the connection when trying to remove the caps revealed one of the two caps on the Siamese FDC had rusted and was unable to be removed. The FDC shall be readily available to allow for fire department hose connection that aids in supplying water to the building fire sprinkler system.

4. Interview with the facilities director at the time of the above observations confirmed those findings. He indicated he was unaware of those fire sprinkler maintenance requirements and believed Building Sprinkler Inc. was providing adequate inspection and testing of these sprinkler system apparatus.

This deficiency has the potential to affect all occupants in the building.

Based on observation and interview, the provider failed to ensure a remote annunciator panel tied to the onsite generator was in a readily accessible location for the essential electric system (EES). Findings include:

1. Observation at 1:15 p.m. on 1/31/17 revealed a security switch board office near the emergency department. That security office was tasked with the responsibility of monitoring building alarms twenty-four hours a day. Further observation revealed no remote annunciator for the onsite generator was available. The annunciator should have been available in a readily observed location to indicate alarm conditions for the generator that provided the back-up electrical power for the type 1 EES.

Interview with the facility director at the time of the above observation confirmed that condition. He indicated he was unaware a remote annunciator for the generator was required in a readily accessible location.