HospitalInspections.org

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. Potentially all patients, staff and visitors could be affected. The facility census was 43 patients at the time of the survey.

Findings include:

On 09/25/12, between 11:20A.M. and 3:30 P.M. tour of the facility was conducted with Staff G and H.

Observation of the paths of egress revealed three exit discharges which required travel across uneven grassy areas to the public way. The following exits in the facility were affected:

* A designated exit in the acute hall was noted to discharge onto a concrete pad estimated to be approximately four feet long by eight feet wide. Travel to the paved, public way was estimated by Staff G and Staff C to be approximately 125 to 150 feet across an uneven, grassy surface.

* Exits located on the 600 Hall (outpatient corridor) and the 300 Hall (expressive therapy corridor) were observed to lead to an enclosed pavilion courtyard. Travel from the cemented pavilion area to the paved public way was estimated by Staff G and H to be approximately 35 to 50 feet across an uneven grassy area.

Interview of Staff G verified the grassy areas which lead to the public way were not routinely maintained in times of inclement weather that could cause the areas to become covered or saturated.

Observation of the acute care unit revealed the presence of two exit doors designated as the second means of egress from the unit. One door was located in the acute (200 corridor) and the second door was located in the adolescent corridor. Observation of both doors revealed the presence of delayed egress locks which unlocked with activation of the fire alarm system. Both doors were also equipped with dead bolt type locks.

Interview of Staff G, revealed the deadbolts were present for staff and patient safety in the event the delayed egress locks became nonfunctional. Staff G further stated the deadbolt locks may have been rendered non functional but remained on the doors. On 09/26/12 the locking mechanism of the deadbolts on both exit doors were removed and were covered with a solid plate cover.

National Fire Alarm Code
NFPA 72, 1999 edition

Chapter 2

2-3.5 Heating, Ventilating, and Air-Conditioning (HVAC).
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
* A-2-3.5.1
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Based on facility observation and staff interview and verification, the facility failed to ensure that smoke detector placement was not placed in spaces serviced by airflow devices that could prevent the operation of the detectors. Potentially all patients, staff and visitors could be affected. The facility census was 43 patients at the time of the survey.

Findings include:

On 09/25/12, between 11:20 A.M. and 3:30 P.M. tour of the facility was conducted with Staff G and H.
Observation of the acute care unit revealed that placement of three smoke detectors was significantly less than 3 feet from airflow devices. Two smoke detectors were located in the acute care hall close to the electrical / mechanical room and the third was located the acute care hall for adolescents, across from room 226.

Staff G present on tour verified the smoke detectors were placed significantly less than 3 feet from the airflow devices.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. Potentially all patients, staff and visitors could be affected. The facility census was 43 patients at the time of the survey.

Findings include:

On 09/25/12, between 11:20A.M. and 3:30 P.M. tour of the facility was conducted with Staff G and H.

Observation of the paths of egress revealed three exit discharges which required travel across uneven grassy areas to the public way. The following exits in the facility were affected:

* A designated exit in the acute hall was noted to discharge onto a concrete pad estimated to be approximately four feet long by eight feet wide. Travel to the paved, public way was estimated by Staff G and Staff C to be approximately 125 to 150 feet across an uneven, grassy surface.

* Exits located on the 600 Hall (outpatient corridor) and the 300 Hall (expressive therapy corridor) were observed to lead to an enclosed pavilion courtyard. Travel from the cemented pavilion area to the paved public way was estimated by Staff G and H to be approximately 35 to 50 feet across an uneven grassy area.

Interview of Staff G verified the grassy areas which lead to the public way were not routinely maintained in times of inclement weather that could cause the areas to become covered or saturated.

Observation of the acute care unit revealed the presence of two exit doors designated as the second means of egress from the unit. One door was located in the acute (200 corridor) and the second door was located in the adolescent corridor. Observation of both doors revealed the presence of delayed egress locks which unlocked with activation of the fire alarm system. Both doors were also equipped with dead bolt type locks.

Interview of Staff G, revealed the deadbolts were present for staff and patient safety in the event the delayed egress locks became nonfunctional. Staff G further stated the deadbolt locks may have been rendered non functional but remained on the doors. On 09/26/12 the locking mechanism of the deadbolts on both exit doors were removed and were covered with a solid plate cover.

National Fire Alarm Code
NFPA 72, 1999 edition

Chapter 2

2-3.5 Heating, Ventilating, and Air-Conditioning (HVAC).
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
* A-2-3.5.1
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Based on facility observation and staff interview and verification, the facility failed to ensure that smoke detector placement was not placed in spaces serviced by airflow devices that could prevent the operation of the detectors. Potentially all patients, staff and visitors could be affected. The facility census was 43 patients at the time of the survey.

Findings include:

On 09/25/12, between 11:20 A.M. and 3:30 P.M. tour of the facility was conducted with Staff G and H.
Observation of the acute care unit revealed that placement of three smoke detectors was significantly less than 3 feet from airflow devices. Two smoke detectors were located in the acute care hall close to the electrical / mechanical room and the third was located the acute care hall for adolescents, across from room 226.

Staff G present on tour verified the smoke detectors were placed significantly less than 3 feet from the airflow devices.