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Based on observation, the facility failed to provide elevator shafts that are enclosed with construction that have a fire resistance rating of at least one hour for 2 of 12 elevators in the facility. This deficiency affects all 141 patients in the facility.

Findings:

During an inspection of the elevators shafts on July 8, 2010 between 10:00 a.m., and 12:00 p.m. it was observed that the following elevators had areas of the shafts that were not one-hour fire resistive.

1. The shaft for elevators 5& 6 has a 2 ft. by 10 ft. area of the wall missing. This area is best observed from the second floor of elevator # 6.

2. The shaft for elevator 7 &8 has an antenna wire is that is penetrating the wall at the fifth floor. The wire comes from the penthouse into the shaft and thought the wall between the entrance of elevator 7 and elevator 8.

Based on observation the facility failed to provide proper protection to all hazardous areas as per NFPA 101 (Life Safety Code). This deficiency affects 15 patients in the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility between July 7 & July 9, 2010 observation revealed that following areas did not have doors that were self-closing.

1. The door to the Soiled Utility room in the Cath Lab holding area, was not self-closing.

2. The door to GI Procedure room #5, currently being used as supply storage, was not self-closing.

Based on visual observation the facility failed to provide key over rides switch at each exit door with a magnetic lock for 5 of 6 exit doors. This deficiency affects 18 patients in this unit.

NFPA 101: 19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times.

Findings:

During a tour of building on July 7, 2010 between 9:00 a.m. and 10:30 a.m., it was revealed that the exit door going out Unit 54 on the fifth floor was observed to have magnetic lock installed on each. The Office of State Fire Marshal permits Magnetic locks on exit doors if they unlock upon activation of the fire alarm and loss of power with no automatic re-locking capabilities, key overrides at each door that is not in view of the nurses station, with all staff having a key, and a remote release at a nurses station. All of the requirements were met with the exception of the key overrides at each door.

Based on observation the facility failed to provide corridors that are clear and unobstructed for the complete width of the corridor for 1 of 4 units on the 5th floor of the facility. This deficiency affects 29 of 56 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101:7.3. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 31/2 in. on each side shall be permitted at 38 in. and below.

Findings:

During a tour of the facility on July 7, 2010 between 8:30 a.m. and 4:30 p.m. there were carts blocking the corridor in Unit 51 of the 5th floor in the following areas. Observations at 8:55a.m., 9:55a.m. & 10:30a.m. Revealed that these items were left unattended in the same locations for more then thirty minutes.

Isolation carts were left in the unattended in the corridor by rooms 5133, 5137, and 5139. The carts are eighteen inches by nineteen inches.

Items left in the corridors would prevent the rapid removal of patients in case of a fire or disaster.

Base on observation the facility failed to assure that all parts of the electrical system in the facility is in accordance with NFPA 70 (National Electric Code). This deficiency could affect all 141 patients in the facility.

Findings:

During a tour of the facility between July 7 and July 9, 2010 it was observed that the following areas have duplex outlets that are within six feet of a sink and did not without ground-fault circuit interrupter (GFIC).

1. The Kitchen / Nutrition rooms of the ICU, Lab and unit 31, 33, 41, 43, 44, 51, 53, & 54 have outlets near the sinks.

2. The supply room on unit 31, Blood Bank in the Lab, and the nurse lounge on units 51, 52, 53, & 54.

Based on observation, the facility failed to provide elevator shafts that are enclosed with construction that have a fire resistance rating of at least one hour for 2 of 12 elevators in the facility. This deficiency affects all 141 patients in the facility.

Findings:

During an inspection of the elevators shafts on July 8, 2010 between 10:00 a.m., and 12:00 p.m. it was observed that the following elevators had areas of the shafts that were not one-hour fire resistive.

1. The shaft for elevators 5& 6 has a 2 ft. by 10 ft. area of the wall missing. This area is best observed from the second floor of elevator # 6.

2. The shaft for elevator 7 &8 has an antenna wire is that is penetrating the wall at the fifth floor. The wire comes from the penthouse into the shaft and thought the wall between the entrance of elevator 7 and elevator 8.

Based on observation the facility failed to provide proper protection to all hazardous areas as per NFPA 101 (Life Safety Code). This deficiency affects 15 patients in the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility between July 7 & July 9, 2010 observation revealed that following areas did not have doors that were self-closing.

1. The door to the Soiled Utility room in the Cath Lab holding area, was not self-closing.

2. The door to GI Procedure room #5, currently being used as supply storage, was not self-closing.

Based on visual observation the facility failed to provide key over rides switch at each exit door with a magnetic lock for 5 of 6 exit doors. This deficiency affects 18 patients in this unit.

NFPA 101: 19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times.

Findings:

During a tour of building on July 7, 2010 between 9:00 a.m. and 10:30 a.m., it was revealed that the exit door going out Unit 54 on the fifth floor was observed to have magnetic lock installed on each. The Office of State Fire Marshal permits Magnetic locks on exit doors if they unlock upon activation of the fire alarm and loss of power with no automatic re-locking capabilities, key overrides at each door that is not in view of the nurses station, with all staff having a key, and a remote release at a nurses station. All of the requirements were met with the exception of the key overrides at each door.

Based on observation the facility failed to provide corridors that are clear and unobstructed for the complete width of the corridor for 1 of 4 units on the 5th floor of the facility. This deficiency affects 29 of 56 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101:7.3. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 31/2 in. on each side shall be permitted at 38 in. and below.

Findings:

During a tour of the facility on July 7, 2010 between 8:30 a.m. and 4:30 p.m. there were carts blocking the corridor in Unit 51 of the 5th floor in the following areas. Observations at 8:55a.m., 9:55a.m. & 10:30a.m. Revealed that these items were left unattended in the same locations for more then thirty minutes.

Isolation carts were left in the unattended in the corridor by rooms 5133, 5137, and 5139. The carts are eighteen inches by nineteen inches.

Items left in the corridors would prevent the rapid removal of patients in case of a fire or disaster.

Base on observation the facility failed to assure that all parts of the electrical system in the facility is in accordance with NFPA 70 (National Electric Code). This deficiency could affect all 141 patients in the facility.

Findings:

During a tour of the facility between July 7 and July 9, 2010 it was observed that the following areas have duplex outlets that are within six feet of a sink and did not without ground-fault circuit interrupter (GFIC).

1. The Kitchen / Nutrition rooms of the ICU, Lab and unit 31, 33, 41, 43, 44, 51, 53, & 54 have outlets near the sinks.

2. The supply room on unit 31, Blood Bank in the Lab, and the nurse lounge on units 51, 52, 53, & 54.