HospitalInspections.org

Based on observation and interview, the doors protecting corridor openings failed to meet protective requirements.

Findings include:

On 3/25/15 the following corridor doors were not provided with a suitable means for keeping the doors closed as required. There was visible evidence that the doors were positive latching at one time and were altered so that they no longer positive latching.
· Surgical suite north side, 2nd floor
· Surgical suite south side, 2nd floor
· Door 2A3-20, ICU
· Door 2A1-22, Med Surgery
On 3/26/15 the following corridor doors were not provided with a suitable means for keeping the doors closed as required. There was visible evidence that the doors were positive latching at one time and were altered so that they no longer positive latching.
· Radiology department west door
· Physical Therapy Door 1C1-21
Ref: 2000 NFPA 101 Section 19.3.6.3.2, 4.6.7, 18.3.6.3.2

On 3/25/15 the following corridor doors were equipped with latches that did not keep the door closed. Fire protective equipment is required to be maintained. The following doors were not maintained as required.
· Door 2A1-28, storage room
· Door 2A2-03, patient room
· 2A2-14, patient room
On 3/26/15 the following corridor doors were equipped with latches that did not keep the door closed. Fire protective equipment is required to be maintained. The following doors were not maintained as required.
· Dental Door 1D2-01
· Door 1B1-20, Engineering, automatic flush bolts non functional

Ref: 2000 NFPA 101 Section 19.3.6.3.2, 4.6.7, 18.3.6.3.2, 4.6.12.1
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to maintain corridor doors as required increases the risk of death or injury due to fire.

The deficiency affected 11 of numerous corridor doors.

Based on observation and interview, the facility failed to protect vertical openings as required.

Findings include:

On 3/25/15 the doors protecting atrium openings did not latch as required. There was evidence that the doors latched were positive latching before being altered. Atrium doors are required to meet opening requirements for corridor walls. Existing corridor wall openings are required to be protected with positive latching doors if they were positive latching before altered.
· Door 2C133
· Door 2C203
· Door 2A508
· Door 2D2-01- electric latch goes to open position if power is lost
· Door 2C3-18, Labor and Delivery
· Atrium door to pharmacy- electric latch goes to open position if power is lost
· Atrium door to contract health- electric latch goes to open position if power is lost
· Atrium door 1F6-24 to ENT - electric latch goes to open position if power is lost
· ENT clinic

On 3/26/15 the doors protecting atrium openings did not latch as required. There was evidence that the doors latched were positive latching before being altered. Atrium doors are required to meet opening requirements for corridor walls. Existing corridor wall openings are required to be protected with positive latching doors if they were positive latching before altered.
· Behavioral Health Door 1A3-21, electric latch is open during business hours

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect vertical openings as required increases the risk of death or injury due to fire.

The deficiency affected 2 of 2 stories.

Ref: 2000 NFPA 101 Section 19.3.1.1 exception 1, 8.2.5.6(1), 8.2.3.2.3.1(2) exception No. 1
Ref: 2000 NFPA 101 Section 19.3.6.3.2, 4.6.7, 18.3.6.3.2

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 3/25/15 the following storage rooms were found to have doors that were not self-closing. Storage rooms that exceed 50 sf in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing.
· PACU supply, 2C1-19, 9ft x 12ft= 108sf
On 3/26/15 the following storage rooms were found to have doors that were not self-closing. Storage rooms that exceed 50 sf in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing.
· Dental storage Door 1D2-27
· Dental storage Door 1D2-28
· Soiled Linen Door 1B1-12, closer needs adjustment
On 3/26/15, the following doors protecting openings to hazardous areas were not being held open as permitted. Hold open devices on doors to hazardous areas are required to release upon detection of smoke by smoke detectors for door release service.

· PT storage area- 24ft x 32 ft, propped open by exercise equipment/ pedal device

Ref: 2000 NFPA 101 Section 19.3.2.1, 7.2.1.8.2, 1999 NFPA 72 Section 2-10.6

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected 5 of numerous hazardous areas.

Ref: 2000 NFPA 101 Section 19.3.2.1

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 3/25/15 the following access controlled egress doors were missing the required " push to exit " button.
· Door 2B2-27, stairwell door, mag lock with motion sensor
· Door 2D2-01, IT door to atrium
· Door 2C2-03
· Door 2A5-08
· 2A3-20, ICU
· Door 2A1-22, Med Surgery
· Door 2A1-23
· Door 2A3-23
· Pharmacy, mag lock with motion sensor, exit sign present above door
· Medical Records Door 26-23, exit sign present above door
· Contract Health Door 1F3-24
· Ambulance entrance
On 3/26/15 the following access controlled egress doors were missing the required " push to exit " button.
· Radiology west door
· Physical Therapy Door 1C1-21
· Dental Door 1D2-01
· Dental Door 1D2-18
Ref: 2000 NFPA 101, Section 19.2.2.2.4, exception 3, 7.2.1.6.2

On 3/25/15 the following doors were found be equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.
· Pharmacy refill room- mag lock requiring proximity card in the direction of egress.
· South entrance sliding door, exit sign present above door
· Emergency Department sliding door, 2 each
· Ambulance entrance sliding door, 2 each
· Exam room 8 emergency department- staff stated that there was no clinical, security or special protective needs.
On 3/26/15 the following doors were found be equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.
· Adolescent Care unit office door 1A4-11-dead bolt w/o release on egress side
· Adolescent Care unit office door 1A4-07-dead bolt w/o release on egress side
· Adolescent Care unit resident rooms, 10 each-dead bolt w/o release on egress side, staff indicated no clinical need to lock doors.
Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1, 19.2.2.2.4

On 3/26/15 the following doors were equipped with two locking/ latching devices where two releasing operations were required to operate the door. Doors in the means of egress are required to be operable with not more than one releasing operation.
· Adolescent Care unit office door 1A4-11-dead bolt and lever latch
· Adolescent Care unit office door 1A4-07-dead bolt and lever latch
· Adolescent Care unit resident rooms, 10 each-dead bolt and lever latch
Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4

On 3/26/15 the following rooms greater than 2,500 square feet in size failed to have to have not less than two exit access door remotely located form each other. Stories used for exclusively for mechanical equipment are permitted to have a single means of egress.
· Basement mechanical/ storage- one exit access door.
Ref: 2000 NFPA 101 Section 19.2.5.3, 19.2.1, 7.12.2

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected 28 aspects of numerous aspects of the means of egress.

Based on observation and interview, the facility failed to provide emergency lighting as required.

Findings include:

On 3/26/15 records indicated that the required annual 90 minute test of battery powered emergency lights had not been conducted in the past 12 months. Records indicate that the required 30 second monthly testing had not been conducted since July 2014.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected a limited number of areas lighted with battery powered lights.

Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.3

Based on observation and interview, the facility failed to test the fire alarm system as required.

Findings include:

On 3/26/15 there was no documentation that the required annual testing audible and visible notification devices of the fire alarm system had been performed in the past year as required.

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to test the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests of the fire alarm system.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 Table 7-3.2 item 19

Based on observation and interview, the facility failed to test smoke detectors as required.

Findings include:

On 3/26/15 there was no record that smoke detector sensitivity testing had been performed as required. Testing is required on alternate years unless previous testing shows that the detectors have remained within its listed and marked sensitivity range. The interval between testing may then be extended to 5 years. There were no records that indicated that the detectors met this requirement or the alternate year testing. The last sensitivity test records were dated 2010.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to test smoke detectors as required increases the risk of death or injury due to fire.

The deficiency affected all smoke detectors in the building.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 Section 7-3.2.1, 7-5.2

Based on observation and interview, the facility failed to protect areas with automatic fire sprinklers as required.

Findings include:

On 3/25/15, the following locations were not protected with automatic fire sprinklers as required:
· Adolescent Care Unit, Room 1A4-11- full height office partitions block sprinkler coverage in front of door.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect all areas with fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous location in the building.

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-1.1

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

On 3/26/15 the facility did not have a special sprinkler wrench for the maintenance of the automatic fire sprinkler system as required.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to maintain automatic fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency one of numerous maintenance requirements of the automatic fire sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 2-4.1.6

Based on observation and interview, the facility failed to have a smoking policy as required.

Findings include:

On 3/26/15 the smoking policy did not prohibit smoking by patients classified as not responsible as required.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to increases the risk of death or injury due to fire.

The deficiency affected one of four required components of a smoking policy.

Ref: 2000 NFPA 101 Section 19.7.4

Based on observation and interview, the facility failed to protect cooking facilities as required.

Findings include:

On 3/26/15, there were no inspection reports for the past year of the required semiannual inspection of the kitchen hood extinguishing system avaialble for review as required. An invoice dated 12/2014 was reviewed, but no inspection report of the work performed was available as required.

Ref: 2000 NFPA 101 Section 19.3.2.6, 9.2.3; 1998 NFPA 96 Section 8-2

On 3/26/15, there were no records of that the hood ventilation system ductwork had been inspected for cleaning or cleaned as required. Kitchen hood systems as used in this facility are required to be inspected semiannually to determine if they are contaminated with deposits from grease-laden vapors. If contaminated, the entire exhaust system is required to be cleaned to bare metal.

Ref: 2000 NFPA 101 Section 19.3.2.6, 9.2.3; 1998 NFPA 96 Section 8-3.1.1, 8-3.1.2

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect cooking facilities as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous locations in the building.

Based on observation and interview, the doors protecting corridor openings failed to meet protective requirements.

Findings include:

On 3/25/15 the following corridor doors were not provided with a suitable means for keeping the doors closed as required. There was visible evidence that the doors were positive latching at one time and were altered so that they no longer positive latching.
· Surgical suite north side, 2nd floor
· Surgical suite south side, 2nd floor
· Door 2A3-20, ICU
· Door 2A1-22, Med Surgery
On 3/26/15 the following corridor doors were not provided with a suitable means for keeping the doors closed as required. There was visible evidence that the doors were positive latching at one time and were altered so that they no longer positive latching.
· Radiology department west door
· Physical Therapy Door 1C1-21
Ref: 2000 NFPA 101 Section 19.3.6.3.2, 4.6.7, 18.3.6.3.2

On 3/25/15 the following corridor doors were equipped with latches that did not keep the door closed. Fire protective equipment is required to be maintained. The following doors were not maintained as required.
· Door 2A1-28, storage room
· Door 2A2-03, patient room
· 2A2-14, patient room
On 3/26/15 the following corridor doors were equipped with latches that did not keep the door closed. Fire protective equipment is required to be maintained. The following doors were not maintained as required.
· Dental Door 1D2-01
· Door 1B1-20, Engineering, automatic flush bolts non functional

Ref: 2000 NFPA 101 Section 19.3.6.3.2, 4.6.7, 18.3.6.3.2, 4.6.12.1
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to maintain corridor doors as required increases the risk of death or injury due to fire.

The deficiency affected 11 of numerous corridor doors.

Based on observation and interview, the facility failed to protect vertical openings as required.

Findings include:

On 3/25/15 the doors protecting atrium openings did not latch as required. There was evidence that the doors latched were positive latching before being altered. Atrium doors are required to meet opening requirements for corridor walls. Existing corridor wall openings are required to be protected with positive latching doors if they were positive latching before altered.
· Door 2C133
· Door 2C203
· Door 2A508
· Door 2D2-01- electric latch goes to open position if power is lost
· Door 2C3-18, Labor and Delivery
· Atrium door to pharmacy- electric latch goes to open position if power is lost
· Atrium door to contract health- electric latch goes to open position if power is lost
· Atrium door 1F6-24 to ENT - electric latch goes to open position if power is lost
· ENT clinic

On 3/26/15 the doors protecting atrium openings did not latch as required. There was evidence that the doors latched were positive latching before being altered. Atrium doors are required to meet opening requirements for corridor walls. Existing corridor wall openings are required to be protected with positive latching doors if they were positive latching before altered.
· Behavioral Health Door 1A3-21, electric latch is open during business hours

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect vertical openings as required increases the risk of death or injury due to fire.

The deficiency affected 2 of 2 stories.

Ref: 2000 NFPA 101 Section 19.3.1.1 exception 1, 8.2.5.6(1), 8.2.3.2.3.1(2) exception No. 1
Ref: 2000 NFPA 101 Section 19.3.6.3.2, 4.6.7, 18.3.6.3.2

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 3/25/15 the following storage rooms were found to have doors that were not self-closing. Storage rooms that exceed 50 sf in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing.
· PACU supply, 2C1-19, 9ft x 12ft= 108sf
On 3/26/15 the following storage rooms were found to have doors that were not self-closing. Storage rooms that exceed 50 sf in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing.
· Dental storage Door 1D2-27
· Dental storage Door 1D2-28
· Soiled Linen Door 1B1-12, closer needs adjustment
On 3/26/15, the following doors protecting openings to hazardous areas were not being held open as permitted. Hold open devices on doors to hazardous areas are required to release upon detection of smoke by smoke detectors for door release service.

· PT storage area- 24ft x 32 ft, propped open by exercise equipment/ pedal device

Ref: 2000 NFPA 101 Section 19.3.2.1, 7.2.1.8.2, 1999 NFPA 72 Section 2-10.6

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected 5 of numerous hazardous areas.

Ref: 2000 NFPA 101 Section 19.3.2.1

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 3/25/15 the following access controlled egress doors were missing the required " push to exit " button.
· Door 2B2-27, stairwell door, mag lock with motion sensor
· Door 2D2-01, IT door to atrium
· Door 2C2-03
· Door 2A5-08
· 2A3-20, ICU
· Door 2A1-22, Med Surgery
· Door 2A1-23
· Door 2A3-23
· Pharmacy, mag lock with motion sensor, exit sign present above door
· Medical Records Door 26-23, exit sign present above door
· Contract Health Door 1F3-24
· Ambulance entrance
On 3/26/15 the following access controlled egress doors were missing the required " push to exit " button.
· Radiology west door
· Physical Therapy Door 1C1-21
· Dental Door 1D2-01
· Dental Door 1D2-18
Ref: 2000 NFPA 101, Section 19.2.2.2.4, exception 3, 7.2.1.6.2

On 3/25/15 the following doors were found be equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.
· Pharmacy refill room- mag lock requiring proximity card in the direction of egress.
· South entrance sliding door, exit sign present above door
· Emergency Department sliding door, 2 each
· Ambulance entrance sliding door, 2 each
· Exam room 8 emergency department- staff stated that there was no clinical, security or special protective needs.
On 3/26/15 the following doors were found be equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.
· Adolescent Care unit office door 1A4-11-dead bolt w/o release on egress side
· Adolescent Care unit office door 1A4-07-dead bolt w/o release on egress side
· Adolescent Care unit resident rooms, 10 each-dead bolt w/o release on egress side, staff indicated no clinical need to lock doors.
Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1, 19.2.2.2.4

On 3/26/15 the following doors were equipped with two locking/ latching devices where two releasing operations were required to operate the door. Doors in the means of egress are required to be operable with not more than one releasing operation.
· Adolescent Care unit office door 1A4-11-dead bolt and lever latch
· Adolescent Care unit office door 1A4-07-dead bolt and lever latch
· Adolescent Care unit resident rooms, 10 each-dead bolt and lever latch
Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4

On 3/26/15 the following rooms greater than 2,500 square feet in size failed to have to have not less than two exit access door remotely located form each other. Stories used for exclusively for mechanical equipment are permitted to have a single means of egress.
· Basement mechanical/ storage- one exit access door.
Ref: 2000 NFPA 101 Section 19.2.5.3, 19.2.1, 7.12.2

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected 28 aspects of numerous aspects of the means of egress.

Based on observation and interview, the facility failed to provide emergency lighting as required.

Findings include:

On 3/26/15 records indicated that the required annual 90 minute test of battery powered emergency lights had not been conducted in the past 12 months. Records indicate that the required 30 second monthly testing had not been conducted since July 2014.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected a limited number of areas lighted with battery powered lights.

Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.3

Based on observation and interview, the facility failed to test the fire alarm system as required.

Findings include:

On 3/26/15 there was no documentation that the required annual testing audible and visible notification devices of the fire alarm system had been performed in the past year as required.

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to test the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests of the fire alarm system.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 Table 7-3.2 item 19

Based on observation and interview, the facility failed to test smoke detectors as required.

Findings include:

On 3/26/15 there was no record that smoke detector sensitivity testing had been performed as required. Testing is required on alternate years unless previous testing shows that the detectors have remained within its listed and marked sensitivity range. The interval between testing may then be extended to 5 years. There were no records that indicated that the detectors met this requirement or the alternate year testing. The last sensitivity test records were dated 2010.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to test smoke detectors as required increases the risk of death or injury due to fire.

The deficiency affected all smoke detectors in the building.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 Section 7-3.2.1, 7-5.2

Based on observation and interview, the facility failed to protect areas with automatic fire sprinklers as required.

Findings include:

On 3/25/15, the following locations were not protected with automatic fire sprinklers as required:
· Adolescent Care Unit, Room 1A4-11- full height office partitions block sprinkler coverage in front of door.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect all areas with fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous location in the building.

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-1.1

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

On 3/26/15 the facility did not have a special sprinkler wrench for the maintenance of the automatic fire sprinkler system as required.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to maintain automatic fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency one of numerous maintenance requirements of the automatic fire sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 2-4.1.6

Based on observation and interview, the facility failed to have a smoking policy as required.

Findings include:

On 3/26/15 the smoking policy did not prohibit smoking by patients classified as not responsible as required.
The Facility Maintenance Manager was present when the deficiency was identified.

Failure to increases the risk of death or injury due to fire.

The deficiency affected one of four required components of a smoking policy.

Ref: 2000 NFPA 101 Section 19.7.4

Based on observation and interview, the facility failed to protect cooking facilities as required.

Findings include:

On 3/26/15, there were no inspection reports for the past year of the required semiannual inspection of the kitchen hood extinguishing system avaialble for review as required. An invoice dated 12/2014 was reviewed, but no inspection report of the work performed was available as required.

Ref: 2000 NFPA 101 Section 19.3.2.6, 9.2.3; 1998 NFPA 96 Section 8-2

On 3/26/15, there were no records of that the hood ventilation system ductwork had been inspected for cleaning or cleaned as required. Kitchen hood systems as used in this facility are required to be inspected semiannually to determine if they are contaminated with deposits from grease-laden vapors. If contaminated, the entire exhaust system is required to be cleaned to bare metal.

Ref: 2000 NFPA 101 Section 19.3.2.6, 9.2.3; 1998 NFPA 96 Section 8-3.1.1, 8-3.1.2

The Facility Maintenance Manager was present when the deficiency was identified.

Failure to protect cooking facilities as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous locations in the building.