HospitalInspections.org

Based on observation and interview, it was determined the facility failed to ensure exterior walking surfaces were maintained according to National Fire Protection Association (NFPA) standards. This deficiency had the potential to affect patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code tour on 07/24/19 at 10:00 AM with Maintenance staff, revealed deteriorating and loose sections of sidewalk near the stairs at the D wing exit. Exterior exit surfaces must be maintained to the public way.

An interview with Maintenance staff on 07/24/19 at 10:00 AM revealed they were aware of the deteriorating section of sidewalk and were planning to repair it.

The findings were reported to the Administrator at exit.

Reference: NFPA 101 (2012 Edition).

7.1.6.4* Slip Resistance. Walking surfaces shall be slip resistant
under foreseeable conditions. The walking surface of
each element in the means of egress shall be uniformly slip
resistant along the natural path of travel.

Based on an interview and record review, it was determined the facility failed to maintain the fire alarm system according to National Fire Protection Association (NFPA) standards. This deficiency had the potential to affect patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code tour on 07/24/19 at 11:10 AM with Maintenance staff, a record review of the last quarterly inspection of the fire sprinkler system in January 2019 revealed that two (2) smoke detectors and one (1) visual indicator were not operating correctly at that time.

An interview with Maintenance staff on 07/24/19 at 11:10 AM revealed he was not sure if this condition had been corrected; however, had no documented evidence that the smoke detectors and indicator had been repaired.

The findings were reported to the Administrator at exit.

Based on an interview and record review, it was determined the facility failed to maintain the fire sprinkler system according to National Fire Protection Association (NFPA) standards. This deficiency had the potential to affect patients, staff, and other occupants of the building.

The findings include:

During the Life Safety Code tour on 07/24/19 at 11:20 AM with Maintenance staff, a record review revealed a quarterly sprinkler inspection was last performed on 01/31/19. There was no record of that an inspection of the fire sprinkler system had been completed since this date.

An interview with Maintenance staff on 07/24/19 at 11:20 AM revealed the sprinkler inspection was overlooked.

The findings were reported to the Administrator at exit.