HospitalInspections.org

Based on observations and interviews during the survey for life safety from fire with the facility's Life Safety Officer (Employee #1) and Medical Sub Director (Employee #2), the facility has locking devices on egress doors leading from the main hall towards the admission department, the back door from the admissions department to the outside, the front main entrance door and door that is located within the Emergency room that leads to the ambulance bay which is not in accordance with the 2012 edition of the Life Safety Code of the NFPA 101 Section 7.2.1.6.1.

Findings include:

1. During the tour for life safety from fire of the hospital on 7/8/2021 from 8:30 AM till 11:30 AM with Employee #1 and #2, it was found that doors in required means of egress were equipped with locks that require the use of a tool or key from the egress side, this was observed in the following areas of the hospital:

a. The back door from the admissions department which leads to the outside of the hospital into the courtyard area near the cafeteria was observed on 7/8/2021 at 9:05 AM. Employees #1 and #2 were interviewed on 7/8/2021 at 9:06 AM and they stated that this door is locked after 6:00 PM after the admissions department is closed. However, the evacuation plan in the main hallway before the admissions department was observed on 7/8/2021 at 9:16 AM and provided evidence that the egress route is through the admissions department and through the door that leads to the outside. The hospital failed to ensure that this required means of egress door is maintained unlocked at all times or has a device on the door which allows persons to open this door by pushing it in one motion.

b. The smoke barrier door located before the admissions department and clinical laboratory was observed on 7/8/2021 at 9:15 AM. Employees #1 and #2 were interviewed on 7/8/2021 at 9:16 AM and they stated that this door is locked after 6:00 PM after the admissions department is closed, personnel in the laboratory have another exit door that is near the main entrance of the hospital so they do not need to go through the locked smoke barrier door. However, the evacuation plan in the main hallway before the admissions department was observed on 7/8/2021 at 9:16 AM and provided evidence that the egress route is through the admissions department and through the smoke barrier door which then leads to the back door and then the outside. The hospital failed to ensure that this required means of egress door is maintained unlocked at all times or has a device on the door which allows persons to open this door by pushing it in one motion.

c. The emergency exit egress door located at the main entrance/exit of the hospital which leads out to the front parking area was observed on 7/8/2021 at 9:30 AM. Employees #1 and #2 were interviewed on 7/8/2021 at 9:35 AM and they stated that this door is locked during the night and only unlocked during the day. However, the evacuation plans located in the hallway near the admissions department and in the hallway near the X-Ray department were observed on 7/8/2021 at 9:40 AM and provided evidence that one of the egress routes is through this front door of the hospital. The hospital failed to ensure that this required means of egress door is maintained unlocked at all times or has a device on the door which allows persons to open this door by pushing it in one motion.

d. The emergency exit egress door located within the Emergency Room which leads out to the ambulance bay was observed on 7/8/2021 at 9:57 AM. Employees #1 and #2 were interviewed on 7/8/2021 at 9:58 AM and they stated that this door is locked during the day and night and only unlocked when an ambulance arrives with a patient on a gurney. However, the evacuation plan located within the Emergency Room was observed on 7/8/2021 at 10:15 AM and provided evidence that one of the egress routes is through this door that leads out to the ambulance bay and to the outside. The hospital failed to ensure that this required means of egress door is maintained unlocked at all times or has a device on the door which allows persons to open this door by pushing it in one motion.

e. The emergency exit egress door located next to patient room #110 (first floor) which leads to the outside of the hospital into the courtyard area near the cafeteria as observed on 7/8/2021 at 10:30 AM. Employees #1 and #2 were interviewed on 7/8/2021 at 10:31 AM and they stated that this door is connected to the fire alarm system and only opens if the fire alarm is activated. The sign above the door states "Emergency Use Only". The hospital failed to ensure that this required means of egress door is maintained unlocked at all times or has a device on the door which allows persons to open this door by pushing it in one motion.

f. The emergency exit egress door located next to patient room #105 (first floor) which leads to the outside of the hospital into the courtyard area near the cafeteria as observed on 7/8/2021 at 10:42 AM. Employees #1 and #2 were interviewed on 7/8/2021 at 10:44 AM and they stated that this door has a keypad which requires a number code in order to release the magnetic door lock and only opens when the keypad is used. The sign above the door states "Emergency Use Only". The hospital failed to ensure that this required means of egress door is maintained unlocked at all times or has a device on the door which allows persons to open this door by pushing it in one motion.

g. 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. At the bottom of the stairs is a small metal gate that has a latch that hold the gate in the closed position, which requires the latch to be lifted upward and pulled to the left in order to gain access to the ground floor. Employees #1 and #2 were interviewed on 7/8/2021 at 10:51 AM and they stated that this gate has a latch so that people walking on the ground level do not go up the stairs. The hospital failed to ensure that this required means of egress door is maintained unlocked/unlatched at all times or has a device on the gate which allows persons to open this gate by pushing it in one motion.

Based on observations made during the survey for 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 Sections 19.2, 19.2.1,19.2.7, 7.7, 7.7.1, 7.7.1.1, 7.7.3.2, 7.1, 7.1.7.1, 7.1.7.2.4 and 7.1.8.

Findings include:

1. During the tour for 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.

Based on observations made during the survey for life safety from fire the facility failed to provide emergency illumination that would operate automatically along the means of egress and failed to have the required illuminance with two lamps energized during emergencies in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.8, 7.8, 7.8.1.1, 7.8.1.2, 7.8.1.4 and 7.9.2.1.

Findings include:

1. During the tour for life safety from fire, 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.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #1)and Medical Sub Director (Employee #2), it was determined that the facility failed to provide emergency lighting (battery operated lamps) in accordance with the 2019 State Law requirements Chapter 25, Article 4 section 3 and Article 5 section 1 and the 2018 Fire Department Code Chapter 10 section 1008.

Findings include:

1. The facility lacks emergency lighting (battery operated lamp) in the hallway of the X-Ray department of 90 minutes as observed on 7/8/2021 at 9:57 AM with Employees #1 and #2. Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails.

2. The facility lacks emergency lighting (battery operated lamp) in the hallway near patient's room #211 of 90 minutes as observed on 7/8/2021 at 10:34 AM with Employees #1 and #2. Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails.

3. The facility lacks emergency lighting (battery operated lamp) in the hallway in front of the Pediatric Intensive Care Unit (P.I.C.U) of 90 minutes as observed on 7/8/2021 at 10:45 AM with Employees #1 and #2. Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails.

4. Observations on 7/8/2021 at approximately 10:31 AM of the medical surgery (patient room #214) revealed all lighting, including the emergency lights could be powered off. The switch in the corridor supplies normal and emergency lighting for the means of egress and had no emergency lighting when the switch was in the off position.

5. Observations on 7/8/2021 at approximately 10:52 AM of the secondary corridor (patient room #227) revealed that all lighting, including the emergency lights could be powered off. The switch in the corridor supplies normal and emergency lighting for the means of egress and did not have emergency lighting when the switch was in the off position.

6. Observations on 7/8/2021 at approximately 10:55 AM of the main corridor revealed that all lighting could be powered off. The switch in the corridor supplied normal and emergency lighting for the means of egress and did not have emergency lighting when the switch was in the off position.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #1) and Medical Sub Director (Employee #2), it was determined that the facility failed to provide compliant exit signs in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.9.1, 7.9, 7.9.2, 7.9.2.3, 7.9.3.1.1, 7.10.9, 19.2.10, 7.10, 7.10.1.2.1, 7.10.7.2, 7.10.8, 7.10.8.1, 7.10.5, 7.10.6.3, 7.10.7, 7.10.7.1, 7.10.9.1 and 19.2.10.1.

Findings include:

1. During the tour for life safety from fire, entrance/exit components and means of egress were verified with Employees #1 and #2 and it was found that the means of egress doors of the front main exit (in front of the staircase) and above the smoke barrier doors located near the X-ray department did not have exit signs displayed in a manner that will lead persons safely and quickly to the outside of the hospital as observed on 7/8/2021 at 9:43 AM.

2. During the observational tour of the hospital on 7/8/2021 from 8:30 AM till 11:30 AM with Employees #1 and #2, it was determined that all exit signs located throughout the hospital are glow in the dark and are not equipped with continuous illumination that is supplied by the emergency lighting system. All exit signs need to be continuously illuminated and also needs to be served by the emergency lighting system.

3. During document review of the monthly testing on illuminated exit signs on 7/8/2021 at approximately 1:45 pm and interview with Employee #1 on 7/8/2021 at approximately 1:50 PM, no evidence was found of monthly testing of the illuminated exit signs, or records of photoluminescent signs glow-in-the-dark functionality inspection reports and ANSUL/UL 924 listings for the signs.

4. Observations on 7/8/2021 at approximately 9:18 AM during the facility tour revealed that the exterior exit door adjacent to the Laboratory has a photoluminescent exit sign that was not continuously illuminated.

5. Observations on 7/8/2021 at approximately 10:10 AM during the facility tour revealed that the ambulance exit door has a photoluminescent exit sign that was not continuously illuminated.

Based on observations and review of maintenance documents during the survey for life safety from fire with the facility's Safety Officer (Employee #1) and Medical Sub Director (Employee #2), it was determined that the facility 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 Sections 9.6.1.3 and NFPA 72 section 14.4.5.3.1 and 14.4.5.3.2.

Findings include:

1. 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 life safety from fire with the facility's Safety Officer (Employee #1)and Medical Sub Director (Employee #2), it was determined that the facility failed to ensure that all components of the standpipe system are properly maintained which is not in accordance with NFPA 13 of the Life Safety Code.

Findings include:

During the observational tour of the facility on 7/8/2021 at 11:02 AM with Employees #1 and #2, it was found that the hospitals has a Fire Department Connection (Siamese) on the outside wall of the administrative building employee parking area. However, the connection caps were painted over and did not allow for easy removal by the Fire Department as required, also the caps did not have chains which would allow them to hang from the connection when removed and a sign identifying this connection was not present.

Based on observations of the facility made during the survey for life safety from fire with the facility's Safety Officer (Employee #1) and Medical Sub Director (Employee #2) and interview, 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.

Findings include:

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, document review and interview during the survey for life safety from fire with the facility's Life Safety Officer (Employee #1), it was determined that the facility failed to ensure that the Essential Electric System (Generator) has a remote manual stop station and failed to conduct fuel quality tests of the fuel for the emergency generator at least annually using tests approved by the American Society for Testing and Materials (ASTM) standards in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.5.1, 19.5.1.1, 9.1, 9.1.2, 9.1.3 and 9.1.3.1, NFPA 110, 2010 Edition, Section 5.6.5.6 and 8.3.8.

Findings include:

1. During observations on 7/8/2021 at approximately 9:04 AM during the facility tour, it was identified that the facility's generator was outside and encased. Inside the generator encasement was the emergency shut off. Further observation revealed that there was no remote manual stop station to prevent inadvertent or unintentional operation located outside the room housing the prime mover.

2. During document review on 7/8/2021 at approximately 1:45 PM, no evidence was found of diesel fuel testing and Employee #1 stated during an interview on 7/8/2021 at approximately 1:46 PM that the outside contractor that inspected and tested the facility's emergency generator did not conduct annual testing of the diesel fuel for the emergency generator.

Based on observations of the facility's outside oxygen storage area with the Safety Officer (Employee #1) and interview, it was determined that the facility failed to ensure that full oxygen cylinders are marked to avoid confusion and that oxygen cylinders stored in the open are protected from weather in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA Sections 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Findings include:

1. Six (6) Type E oxygen cylinders were found in the outdoor oxygen storage area without a sign indicating if they were full or empty on 7/8/2021 at 8:49 AM. Full and empty oxygen cylinders are maintained in this outside area that was designed for the two large liquid oxygen tanks which are all located behind a sliding metal locked gate, however a proper sign indicating their full or empty status is required to ensure that full tanks can be retrieved from this area in a quick and safe manner if needed during an emergency.

2. Six (6) full Type H oxygen cylinders were found in the outdoor oxygen storage area chained to the wall to kept them from tipping over on 7/8/2021 at 8:50 AM, however they were placed directly on the cement floor and the bottom of the cylinders were rusty. Employee #1 stated during an interview on 7/8/2021 at 8:55 AM that these tanks are transported for use into the hospital when needed. Also, the oxygen cylinders were not protected from the weather.