HospitalInspections.org

Based on an initial survey Medicare survey, observations interviews, review of documents and observations made during the survey for Life Safety from Fire on 07/08/21 from 8:30 AM through 11:30 AM it was determined that the facility failed to provide an environment that promote the physical safety and well-being of all patients in the area the facility does not meet some applicable provision of the Life Safety Code Existing 2012 edition of the NFPA 101, cited Tags K0222, K0271, K0281, K0291, K0293, K0345, K0353, K0711, K0918 and K0923. All the above findings make this condition "Not Met".

Based on observations made during the survey for emergency preparedness and life safety from fire and the facility failed to provide emergency illumination that would operate automatically along the means of egress, failed to have the required illuminance with two lamps energized during emergencies, failed to ensure that fire alarm smoke annual maintenance is properly performed and no evidence was found of the credentials/qualification and license of the person who performed the tests which is not in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101.

Findings include:

1. During the tour for life safety from fire and emergency preparedness, emergency lighting along means of egress were verified with Employees #1 and #2 and the following was determined:

a. Observations on 7/8/2021 at approximately 9:15 AM revealed that the exterior exit door which leads into the admissions department and Laboratory department had only a single bulb emergency lighting fixture.

b. Observations on 7/8/2021 at approximately 9:35 AM revealed that the main entrance/exit door did not have emergency lighting fixture.

c. Observations on 7/8/2021 at approximately 9:52 AM revealed that the Emergency Room entrance/exit door did not have emergency lighting fixture.

d. Observation on 7/8/2021 at approximately 9:54 AM revealed that the Emergency Room has an exit door adjacent to the waiting room area which did not have emergency lighting fixture.

e. Observations on 7/8/2021 at approximately 9:57 AM revealed that the Emergency Room ambulance exit door did not have emergency lighting fixture.

f. Observations on 7/8/2021 at approximately 10:20 AM revealed that the exit door adjacent to patient room #110 did not have emergency lighting fixture.

g. Observations on 7/8/2021 at approximately 10:24 AM revealed that the exit door adjacent to patient room #105 did not have emergency lighting fixture.

h. Observations on 7/8/2021 at approximately 10:34 AM revealed that the second-floor exit door across from patient room #211 did not have emergency lighting fixture.

i. Observations on 7/8/2021 at approximately 10:36 AM revealed that the second-floor exit door across from patient room #201 did not have emergency lighting fixture.

j. Observations on 7/8/2021 at approximately 10:46 AM revealed that the second-floor exit door adjacent to the Pediatric Intensive Care Unit (PICU) did not have emergency lighting fixture.


2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year (performed on 1/29/2021) as evidenced on 7/8/2021 at 2:02 PM with Employee #1, however no evidence was found of following:

a. No evidence was provided of the annual test for the facility's Strobe Lights (25 total strobe lights).
b. No evidence was provided of the annual test for the facility's Heat Detectors (3 total heat detectors).
c. No evidence was provided of the annual test for the facility's magnetic door hold open devices connected to the fire alarm panel.
d. No evidence was found of the training qualification and license of the person who performed the tests on the fire alarm system.

Based on observations made during the survey for emergency preparedness and life safety from fire on the first and second floors patient areas and emergency room area with the facility's Safety Officer (Employee #1) and Medical Sub Director (Employee #2), it was determined that the facility failed to provide Life Safety Code compliant exit discharges in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101, and it was determined that the facility failed to ensure that there is an evacuation plan located in the waiting area of the emergency room in accordance with the 2018 Fire Department Code Chapter 10 section 1006 provide a safe evacuation during emergencies which can affect all patients and visitors at the hospital.

Findings include:

1. During the tour for emergency preparedness and life safety from fire , exit discharges were verified with Employees #1 and #2 and the following was determined:

a. Observations on 7/8/2021 at approximately 9:52 AM revealed that the Emergency Room entrance/exit included a landing and a six-inch step (approximately) that formed part of a curb onto the vehicular way that was not readily apparent.

b. Observations on 7/8/2021 at approximately 9:57 AM revealed that the ambulance door exit discharge from the Emergency Room included a landing with one side open for ambulances to drop off patients on gurneys, approximately thirty-four inches above ground level that had no guard rail system or edge protection and the steps that were on the opposite side were not readily apparent.

c. Observations on 7/8/2021 at approximately 10:20 AM revealed that the exit adjacent to room #110 included a ramp that did not have handrails on both sides and the cement surface was cracked and uneven.

2. During the tour of the hospital's discharge from exits on 7/8/2021 at 9:15 AM with Employees #1 and #2, it was determined that the back door from the admissions department, the emergency exit egress door located next to patient Room #110 (first floor), the emergency exit egress door located next to patient Room #105 (first floor) and the emergency exit egress door located in front of the Pediatric Intensive Care Unit (P.I.C.U) (second floor) all lead to an outside area of the hospital into a courtyard near the cafeteria. However, this is an enclosed area where administration personnel park their cars and there are walls and gates which does not allow persons who discharged from the hospital to gain access to the public walk way.

3. The emergency exit egress door located in front of the Pediatric Intensive Care Unit (P.I.C.U) on the second floor leads to a roof top area and there is a cement stairs that leads persons down to the ground level as observed on 7/8/2021 at 10:50 AM. The cement stairs has one side that is opened to the outside and has a bannister from the top of the stairs to the bottom and the other side of the stairs has a wall that is part of the hospital. However the wall has a section with approximately twelve glass blocks (each block measured approximately 11.5 inches x 11.5 inches) which will not protect the integrity of this exit route if there is a fire within the building on the interior side of the glass blocks.

4. No evidence was found in the waiting area of the emergency room on 7/8/2021 at 9:58 AM with Employee #1 and #2 of an evacuation plan so personnel and visitors can identify the different egress exit routes, fire extinguisher location and you are here information. Employee #1 stated during an interview on 7/8/2021 at 9:59 AM that the evacuation plan was located near the front door but someone probably took it down, evacuation plans will need to be fixed to the walls to avoid easy removal by unauthorized persons.

Based on observations made during the survey for emergency preparedness and life safety from fire on the first and second floors patient areas and emergency room area with the facility's Safety Officer (Employee #1) and Medical Sub Director (Employee #2), it was determined that the facility failed to provide Life Safety Code compliant exit discharges in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101, and it was determined that the facility failed to ensure that there is an evacuation plan located in the waiting area of the emergency room in accordance with the 2018 Fire Department Code Chapter 10 section 1006 provide a safe evacuation during emergencies which can affect all patients and visitors at the hospital.

Findings include:

1. During the tour for emergency preparedness and life safety from fire , exit discharges were verified with Employees #1 and #2 and the following was determined:

a. Observations on 7/8/2021 at approximately 9:52 AM revealed that the Emergency Room entrance/exit included a landing and a six-inch step (approximately) that formed part of a curb onto the vehicular way that was not readily apparent.

b. Observations on 7/8/2021 at approximately 9:57 AM revealed that the ambulance door exit discharge from the Emergency Room included a landing with one side open for ambulances to drop off patients on gurneys, approximately thirty-four inches above ground level that had no guard rail system or edge protection and the steps that were on the opposite side were not readily apparent.

c. Observations on 7/8/2021 at approximately 10:20 AM revealed that the exit adjacent to room #110 included a ramp that did not have handrails on both sides and the cement surface was cracked and uneven.

2. During the tour of the hospital's discharge from exits on 7/8/2021 at 9:15 AM with Employees #1 and #2, it was determined that the back door from the admissions department, the emergency exit egress door located next to patient Room #110 (first floor), the emergency exit egress door located next to patient Room #105 (first floor) and the emergency exit egress door located in front of the Pediatric Intensive Care Unit (P.I.C.U) (second floor) all lead to an outside area of the hospital into a courtyard near the cafeteria. However, this is an enclosed area where administration personnel park their cars and there are walls and gates which does not allow persons who discharged from the hospital to gain access to the public walk way.

3. The emergency exit egress door located in front of the Pediatric Intensive Care Unit (P.I.C.U) on the second floor leads to a roof top area and there is a cement stairs that leads persons down to the ground level as observed on 7/8/2021 at 10:50 AM. The cement stairs has one side that is opened to the outside and has a bannister from the top of the stairs to the bottom and the other side of the stairs has a wall that is part of the hospital. However the wall has a section with approximately twelve glass blocks (each block measured approximately 11.5 inches x 11.5 inches) which will not protect the integrity of this exit route if there is a fire within the building on the interior side of the glass blocks.

4. No evidence was found in the waiting area of the emergency room on 7/8/2021 at 9:58 AM with Employee #1 and #2 of an evacuation plan so personnel and visitors can identify the different egress exit routes, fire extinguisher location and you are here information. Employee #1 stated during an interview on 7/8/2021 at 9:59 AM that the evacuation plan was located near the front door but someone probably took it down, evacuation plans will need to be fixed to the walls to avoid easy removal by unauthorized persons.