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Based on record review and interview, the facility failed to maintain an Emergency Preparedness plan that is reviewed and updated annually. This deficient practice could result in deficiencies of the emergency management plan to not be addressed or corrected for future actual emergency situations in which the plan is activated, resulting in potential harm to all occupants.


Findings Include:

On 06/17/2018 at approximately 1615 during document review of the emergency management plan, observed there was no evidence that the plan had been reviewed and/or updated within the past twelve months. The revision date shown on the emergency management plan was 1/7/2016. There was one policy within the plan, the communications policy that had been updated on 11/18/2018. Staff I, explained that staff C & staff I met last year to review plans, which were approved with no changes and submitted to the Safety & Quality Committee for approval. The documentation of this approval was not provided. Furthermore, there was no documentation that recommendations for changes to the plan which were identified in the after action reports were incorporated into the written emergency management plan.

Based upon observation and interview, the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06/18/19 at approximately 4:46 PM while performing a physical walk of the path of egress in stairwell 14 on the ground level, or the level of exit discharge, it was observed that there was not a gate preventing persons from traveling to a lower level in the stairwell. This finding was confirmed by interview and observation by employee C at the time of discovery.

2. On 06/18/19 at approximately 2:15 PM while performing a physical walk of the path of egress from the mobile CT trailer, it was observed that when going through the one marked exit door, there was no exit pathway from the trailer, in that it dropped 4-5 feet to the ground. This finding was confirmed by interview and observation by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9 as required by 19.2.9.1. This deficient practice could affect 3 occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06/18/19 at approximately 1:34 PM while performing a visual inspection and functional test of the emergency lighting unit in the Operating Room Recovery Room, it was observed that the light did not function when the test button was depressed. This finding was confirmed by observation and interview by employee P at the time of discovery.

2. On 06/18/19 at approximately 4:26 PM while performing a visual inspection and functional test of the emergency lighting unit in the boiler room above the janitors sink, it was observed that the light did not function when the test button was depressed. This finding was confirmed by observation and interview by employee C at the time of discovery.

3. On 06/18/19 at approximately 4:25 PM while performing a visual inspection and functional test of the emergency lighting unit in the boiler room above the marked exit door by the stairs leading to the exterior of the building, it was observed that the light did not function when the test button was depressed. This finding was confirmed by observation and interview by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06/18/19 at approximately 10:48 AM while performing a visual inspection of the elevator equipment room with employee C, it was observed that there were areas in the walls not properly sealed to meet the requirements of one hour fire rated construction. This finding was confirmed by interview and observation by employee C at the time of discovery.

2. On 06/18/19 at approximately 10:48 AM while performing a visual inspection of the elevator equipment room with employee C, it was discovered there was an air vent in the wall above the door not having a fire damper that would automatically close in the event of a fire in this room. This finding was confirmed by interview and observation by employee C at the time of discovery.

3. On 06/18/19 at approximately 3:13 PM while performing a functional test of the corridor door to the soiled holding room in the Emergency Room, it was discovered that the door would not latch when closed. This finding was confirmed by interview and observation by employee C at the time of discovery.

4. On 06/18/19 at approximately 4:00 PM while performing a functional test of the corridor door to the informational technology (IT) server room, it was discovered that the door would not latch when closed. This room is protected by a FM-200 Fire Extinguishing system, which requires this room to be sealed in the event of actuation of the system. This finding was confirmed by interview and observation by employee C at the time of discovery.

Based upon interview and record review, the facility failed to ensure that cooking facilities are protected in accordance with NFPA 96 unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.4.4 as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, and TIA 12-2. This deficient practice could affect all occupants in the event of fire emergency.

Findings Include:
1. On 06/18/19 at approximately 4:49 PM while conducting an interview with employee X, when questioned about the proper procedure in what to do in the event of a kitchen appliance fire, it became evident by their response that they were not familiar with the proper sequence of things to do in the event of a kitchen appliance fire. Their first response was they would "shut off the gas and call 911". This finding was confirmed by interview with employee C at the time of discovery.

2. On 6/18/19 at approximately 9:35 AM while performing a review of records with employee C, it was learned that according to the document entitled "Range Hood System Report" dated 9-5-18, that the last inspection of the kitchen hood system was performed on that 9-5-18 date, and now has surpassed the required 6 month semi-annual inspection requirement. This finding was confirmed by interview and observation by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that interior wall and ceiling finishes have a flame spread rating of Class A or B unless permitted to be reduced by 10.2.8.1 as required by 19.3.3.1 and 19.3.3.2. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
1. On 06/18/19 at approximately 11:12 AM while performing a visual inspection of the interior finish of the ceiling tiles in room 210, it was observed that there was a ceiling tile with a brown stain. This finding was confirmed by interview and observation by employee C at the time of discovery.

2. On 06/18/19 at approximately 3:15 PM while performing a visual inspection of the interior finish of the ceiling tiles in the emergency department break room, it was observed that there was a ceiling tile with a brown stain. This finding was confirmed by interview and observation by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that a fire alarm system is installed in accordance with NFPA 70 and NFPA 72 as required by 19.3.4.1, 9.6, and 9.6.1.8. This deficient practice could affect all occupants in the event of smoke or fire emergency.

Findings Include:
1. On 06/18/19 at approximately 1:25 PM while conducting a visual inspection of the fire alarm devices in the Operating Room by the schedulers office, it was observed there was a horn and strobe device designed to be mounted on the wall, mounted in the ceiling. This finding was confirmed by interview and observation by employee P at the time of discovery.

2. On 06/18/19 at approximately 1:32 PM while conducting a visual inspection of the fire alarm devices in the Operating Room by the exit door by the clean utility room, it was observed there was a horn and strobe device designed to be mounted on the wall, mounted in the ceiling. This finding was confirmed by interview and observation by employee P at the time of discovery.

Based upon observation, interview and record review the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect all of the occupants in the event of a fire emergency.

Findings Include:

1. On 06/18/19 at approximately 9:29 AM, while performing a review of sprinkler system inspection records with employee C, it was discovered that according to the record entitled "Report of Sprinkler Inspection"dated January 25, 2019, the pressure gauges for the sprinkler system were due to be replaced or re-calibrated during the 2019 annual inspection. The record indicated that the last date the pressure gauges were replaced or recalibrating was in 2014. This finding was confirmed by interview with employee C at the time of discovery.

2. On 06/18/19 at approximately 10:40 AM, while conducting a visual inspection of the sprinkler system above the stairwell in the Attic, it was observed that there was not adequate sprinkler coverage due to a lack of sprinkler heads in this area. This finding was confirmed by interview and observation by employee C at the time of discovery.

3. On 06/18/19 at approximately 12:46 PM, while conducting a visual inspection of the sprinkler piping above the ceiling near the Orthopedic Soiled Utility Room, it was observed that there was a bundle of multiple colored wires that had been taped to the sprinkler pipe. This finding was confirmed by observation and interview by employee C at the time of discovery.

4. On 06/18/19 at approximately 4:34 PM, while conducting a visual inspection of the sprinkler piping above the ceiling in the basement near the electrical access space across from Medical Records, it was observed that there was a bundle of orange and blue wires that had been tied to the sprinkler pipe. This finding was confirmed by observation and interview by employee C at the time of discovery.

5. On 06/18/19 at approximately 3:27 PM, while conducting a visual inspection of the janitors closet across from the CT department, it was observed that the storage of combustible materials was not being maintained 18 inches below the deflector of the sprinkler head. This finding was confirmed by observation and interview by employee C at the time of discovery.

6. On 06/18/19 at approximately 4:20 PM, while conducting a visual inspection of the closet in the Michigan room, it was observed that the storage of combustible materials was not being maintained 18 inches below the deflector of the sprinkler head. This finding was confirmed by observation and interview by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06/18/19 at approximately 11:06 AM, while performing a visual inspection and functional test of the smoke barrier door to the Med Surgical area, it was observed that there was a small magnet in the frame of the doorway, preventing the door from closing. This finding was confirmed by interview and observation by employee C at the time of discovery.

2. On 06/18/19 at approximately 11:14 AM, while performing a visual inspection and functional test of the corridor doors to patient sleeping rooms 11 and 13, it was observed that the doors would not close to a smoke tight seal. This finding was confirmed by interview and observation by employee C at the time of discovery.

3. On 06/18/19 at approximately 11:40 AM, while performing a visual inspection and functional test of the corridor door to patient sleeping room 234, it was observed that the gap at the top edge of the door exceeded one eighth of an inch between the door and the doors frame,causing the door to not form a smoke tight seal. This finding was confirmed by interview and observation by employee C at the time of discovery.

4. On 06/18/19 at approximately 1:51 PM, while performing a visual inspection and functional test of the corridor door to room 106 in the Operating Room, it was observed that the door would not latch when closed, preventing the door from creating a smoke tight seal. This finding was confirmed by interview and observation by employee C at the time of discovery.

5. On 06/18/19 at approximately 1:54 PM, while performing a visual inspection and functional test of the corridor door to the surgical equipment storage room door, it was observed that the doors handle was missing, preventing the door from latching closed. This finding was confirmed by interview and observation by employee C at the time of discovery.

6. On 06/18/19 at approximately 2:11 PM, while performing a visual inspection and functional test of the cross corridor smoke barrier doors by the Short Stay Surgical area, that when the doors were closed the gap at the top of the door exceeded the allowed one eighth inch gap. This finding was confirmed by interview and observation by employee C at the time of discovery.

7. On 06/18/19 at approximately 4:22 PM, while performing a visual inspection and functional test of the cross corridor smoke barrier doors by the Michigan Room, that when closed the doors would not close to a smoke tight seal. This finding was confirmed by interview and observation by employee C at the time of discovery.

Based upon review of records and interview, the facility failed to ensure that fire doors are inspected and maintained in accordance with NFPA 80, and to provide written records of inspection, testing and maintenance of fire doors. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06-18-19 at 9:54 AM during a review of records for the required annual inspection of fire and smoke barrier doors, it was revealed by the record entitled "Annual Rated Fire Door Inspection Summary" dated June 20, 2018, that there were multiple doors that had not passed the annual safety inspection, per a 3rd party inspection company. The report revealed that of the 102 doors inspected, 66 had issues that had not been repaired as of this inspection. This finding was confirmed by interview with employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4, and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect all occupants in the event of smoke or fire emergency where there was a loss of main utility power.

Findings Include:
On 06/18/19 at approximately 3:38 PM during a visual inspection of one of the three emergency generators, it was observed and learned through interview with employee C that there were no remote emergency stop buttons for any of the three generators for this facility. This finding was confirmed by interview and observation with employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that electrical receptacles are maintained and tested as required by 6.3.4 of NFPA 99. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
On 06/18/19 at approximately 3:21 PM while performing a visual inspection of electrical equipment in the Radiological area by the Mamo desk, it was observed there was an electrical outlet that did not have a cover plate. This finding was confirmed by interview and observation by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect all occupants in the event of a smoke or fire emergency.

Findings Include:
1. On 06/18/19 at approximately 11:08 AM while performing a visual inspection of electrical components in the employees break room on the second floor, it was observed that there was an electric toaster plugged into a multi plug power strip. This finding was confirmed by observation and interview by employee C at the time of discovery.

2. On 06/18/19 at approximately 12:54 PM while performing a visual inspection of electrical components in the Case Management Office, it was observed that there was a gray extension cord being used as permanent wiring to power the air conditioning unit. This finding was confirmed by observation and interview by employee C at the time of discovery.

3. On 06/18/19 at approximately 1:42 PM while performing a visual inspection of electrical components in the Operating Room's Clean Supply room, it was observed that there was a blanket warmer plugged into a multi plug power strip. This finding was confirmed by observation and interview by employee C at the time of discovery.

4. On 06/18/19 at approximately 3:56 PM while performing a visual inspection of electrical components in the Informational Technology (IT) Server room, it was observed that there were multi plug power strips daisy chained together. This finding was confirmed by observation and interview by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that all patient-care related electrical equipment is tested and maintained as required by 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, and 10.5.8 of NFPA 99. This deficient practice could affect all occupants in the event of a smoke or fire emergency

Findings Include:
1. On 06/18/19 at approximately 2:34 PM while conducting a visual inspection of the electrical equipment above the ceiling by the Radiology Waiting area, it was observed that there was an open 4 inch by 4 inch electrical junction box that did not have a cover, exposing the electrical wires. This finding was confirmed by interview and observation by employee C at the time of discovery.

2. On 06/18/19 at approximately 2:47 PM while conducting a visual inspection of the electrical equipment above the ceiling in the Lab corridor by the rest room, it was observed that there was an electrical wire that had been cut and abandoned, leaving exposed wires. This finding was confirmed by interview and observation by employee C at the time of discovery.

Based upon observation and interview, the facility failed to ensure that storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could affect all occupants in the event of a smoke or fire emergency

Findings Include:
On 06/18/19 at approximately 5:01 PM, while performing a visual inspection of the office space in the materials Managers Office, it was observed that there was an unsecured oxygen tank sitting on the floor. This finding was confirmed by interview and observation by employee C at the time of discovery.