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Through observation during the survey, December 5 through 14, 2017, it was determined the facility failed to maintain the delayed egress functions on all doors as required.

During the walk through of the facility with the Facility Director;
1) Door set across from room #7749 is labeled as delayed egress, however no delayed egress function on door. Sign needs
to be removed. Note: this deficiency was corrected during the survey
2) Smoke barrier doors and egress doors located in the following areas contained a "pre-alarm" on the delayed egress doors which announced an alarm prior to the door going into the irreversable unlock position.
a) Smoke barrier doors at 6B to 6C
b) Smoke barrier doors at 5E to 5A
c) Door adjacent to room 4386
d) Door adjacent to room 4311,
e) Smoke barrier doors adjacent to restroom #6535
f) Smoke barrier door adjacent to room #5701
g) Door to stair 1 from Observation room to the office area
h) Door from 1G to ED
3) The delayed egress doors, located at the double doors to ED from 1G, were resetting automatically after the delayed egress alarm was completed with the unlock process. No manual means wer necessary to reset the delayed egress alarm.

These deficiencies affected eleven (11) smoke compartments and all resident od staff from those smoke compartments.

Building A-2-Main Hospital

Through observation during the survey, December 5 through 14, 2017, it was determined the facility failed to maintain the doors to the stairwell.

During the walk through of the facility with the Maintenance Director, stairwell door in PACU, stair 3, would not latch into frame. Note:this deficiency was corrected during survey

This deficiency effected 1 stairwell egress out of 4.

Building A-2-Main Hospital

Through observation during the survey, December 5 through December 14 2017, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Facilities Director;
1) Bicycle stored in corridor outside room 5701
2) Sign on corridor outside room 550, this was a large flu sign on a stand
3) Storage in corridor of a bookcase in corridor outside room 1471
Note: All items removed during survey

This deficiency effected theree (3) smoke compartments and 1 means of egress from all three (3) smoke compartments.

Building A-2-Main Hospital

Through observation during the survey, December 5 through December 14, 2017, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.
 
During the walkthrough of the facility, with the Facility Director, thtwo areas contained ABHR's that were located within four feet (4') of each other.
Note: Deficiencies corrected during survey

This deficiency affected 1 smoke compartment throughout the facility

Builing A-2-Main Hospital

Through a review of the records during the survey, December 5 through December 14, 2017, it was determined that the facility failed to maintain records of the sensitivity test of the smoke detectors as required.
 
During the review of the facility records, with the Facility Director, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required.
Note: The sensitivity record was located and provided to the surveyor during the survey

This deficiency affected all staff and residents throughout the hospital.

Building A-2-Main Hospital

Through observation during the survey, December 5 through December 14, 2017, it was determined that the facility failed to space smoke detectors 3' away from all registers as required.
 
During the walk through of the facility with the Facility Director, two (2) spaces contained smoke detectors that weer located within three feet (3') of a return air or exhaust plenum.
1) Smoke detector outside Ortho Care desk was within one foor (1) of return air register
2) Room #4570 is a room open to the corridor with no smoke detector
Note: Both items corrected during survey

This deficiency affected 2 smoke compartments within the facility.

Building A-2-Main Hospital

Through observation during the survey, December 5 through December 14, 2017, it was determined the facility failed to document the fire pump monthly testing requirements properly per NFPA 25.

Fire pumps test report does not indicate the full speed time or the run time during monthly churn tests
Note: This deficiency was corrected during survey-future tests to include this information

This deficiency possibly affected all staff and patients throughout the hospital

Building A-2-Main Hospital

Through observation during the survey, December 5 through December 14, 2017, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Facilities Director, corridor door either contained large gaps between the door and door frame, would not latch into the frame as required, or did not contain positive latching as required;
1) The following rooms contained gaps between the door and door stop which were greater than 1/2" wide at the top portion of the door.
a) Rooms 7124, 7122, 7108, 7124, 6126, 6127, 5321, 5319, 5315, 5110, 5703, 5717, 5512, 4302,
4126, 4716, 1517
2) Door #6102 would not latch into frame which prevented thereforea positive smoke seal could not be maintained..
3)Doors to allof the following rooms contain either a 2 door slide or 3 door slide configuration in which the 2nd door has a manual lock. These doors are the breakaway type of door, however when the manual latch is in the lock position the door will not breakaway and does not positively latch into the frame.
a) Doors 6728, 6729, 6709, 6710 were unlocked during the survey.
b) All doors to ICU rooms (with the exception of 1 door)
c) All NICU room doors
d) All PPU rooms
e) All Pre-Op rooms
f) All ED room doors

These doors affected all patients and staff within the areas listed above. These rooms are all too large to be suites due to square footage requirements.

Building A-2-Main Hospital

Through observation during the survey, December 5 through December 14, 2017, it was determined that the facility failed to maintain the smoke barrier walls.

During the walk through of the facility, with the Facility Director, one (1) smoke wall contained one (1) unsealed penetration at EZ pasth at 5F/5E door (adjacent to room #5730)
Note: Corrected during survey

Building A-2-Main Hospital

Through record review during the survey, December 5 through December 14, 2017, it was determined that the facility failed to conduct fire drills at varying times as required by the Life Safety Code.

During the review of the facility records, with the Facility Director, fire drills for all shifts have been completed, however the time difference on shifts is within 30 minutes of other drills.
Drills must be spaced apart by at least 45 minutes and an hour is preferable.

This deficiency effected all staff and all patients throughout the hospital.