HospitalInspections.org

Based on observation, and staff interviews it was determined that the facility failed to ensure that access to exits are marked by approved, readily visible signs in all cases where the exit or way to reach exits are not readily apparent to occupants.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that
1. Directional components (chevrons) were missing from some exit signage and additional exit signage was required.
2. Directional exit signage was required from Same-Day Recovery unit into the main Emergency Department lobby.
3. Directional exit signage was required from the ground floor to the 1st floor in stairwells.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined that the facility failed to ensure that all hazardous areas were adequately constructed with rated assemblies, or the entire facility was protected with an adequate automatic sprinkler system. Or, certain areas of the facility were being utilized to store hazardous or combustible materials.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that Post-Op area numbers 9-12 were being utilized as storage areas including the storage of combustible materials.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined that the facility failed to ensure that all required smoke detectors are installed, including those activating door hold-open devices, or are approved, maintained, inspected and tested as required.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that:
1. A smoke detector is not installed in the Labor and Delivery waiting room.
2. All doors with door hold-open devices do not have smoke detectors on both sides of the doors.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not noticed that all required smoke detectors were not installed as required.

These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined that the facility failed to ensure that the facility was protected throughout by a code compliant, approved, supervised automatic sprinkler system.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that:
1. All stairwells were not adequately protected by sprinkler coverage including ICU Stairwell Number 5.
2. FDC and Standpipe FDC signage was not in place.
3. Access to all FDCs was not adequate due to landscaping impediments.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not noticed that the facility was not protected throughout by a code compliant, approved, supervised automatic sprinkler system.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined that the facility failed to ensure that all oxygen cylinders were secured as required by NFPA99.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that:
1. Oxygen cylinders were stored in alcoves open to the corridor in multiple corridors and on multiple floors. The quantity of cylinders, and condition of cylinders; full, partially full, or empty, varied from location to location.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not realized that all oxygen cylinders were not secured as required by NFPA99.

These findings were confirmed by Staff M at the time of discovery.

During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that multiple stairwells included handrails and guardrails that are not compliant with NFPA 101, Life Safety Code, Existing Healthcare chapters.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff was not aware of the requirements of NFPA 101, Life Safety Code, Existing Healthcare chapter requirements relative to handrails and guardrails in a stairwell.

These findings were confirmed by Staff M at the time of discovery.

During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that multiple rooms within the facility had power strips being used improperly or were installed improperly, and extension cords were in use in a permanent manner in multiple locations.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not noticed the power strips and extension cords referenced above.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined that the facility failed to ensure that access to exits are marked by approved, readily visible signs in all cases where the exit or way to reach exits are not readily apparent to occupants.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that
1. Directional components (chevrons) were missing from some exit signage and additional exit signage was required.
2. Directional exit signage was required from Same-Day Recovery unit into the main Emergency Department lobby.
3. Directional exit signage was required from the ground floor to the 1st floor in stairwells.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined that the facility failed to ensure that all hazardous areas were adequately constructed with rated assemblies, or the entire facility was protected with an adequate automatic sprinkler system. Or, certain areas of the facility were being utilized to store hazardous or combustible materials.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that Post-Op area numbers 9-12 were being utilized as storage areas including the storage of combustible materials.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined that the facility failed to ensure that all required smoke detectors are installed, including those activating door hold-open devices, or are approved, maintained, inspected and tested as required.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that:
1. A smoke detector is not installed in the Labor and Delivery waiting room.
2. All doors with door hold-open devices do not have smoke detectors on both sides of the doors.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not noticed that all required smoke detectors were not installed as required.

These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined that the facility failed to ensure that the facility was protected throughout by a code compliant, approved, supervised automatic sprinkler system.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that:
1. All stairwells were not adequately protected by sprinkler coverage including ICU Stairwell Number 5.
2. FDC and Standpipe FDC signage was not in place.
3. Access to all FDCs was not adequate due to landscaping impediments.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not noticed that the facility was not protected throughout by a code compliant, approved, supervised automatic sprinkler system.

These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined that the facility failed to ensure that all oxygen cylinders were secured as required by NFPA99.

This could place all patients at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that:
1. Oxygen cylinders were stored in alcoves open to the corridor in multiple corridors and on multiple floors. The quantity of cylinders, and condition of cylinders; full, partially full, or empty, varied from location to location.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not realized that all oxygen cylinders were not secured as required by NFPA99.

These findings were confirmed by Staff M at the time of discovery.

During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that multiple stairwells included handrails and guardrails that are not compliant with NFPA 101, Life Safety Code, Existing Healthcare chapters.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff was not aware of the requirements of NFPA 101, Life Safety Code, Existing Healthcare chapter requirements relative to handrails and guardrails in a stairwell.

These findings were confirmed by Staff M at the time of discovery.

During a tour of the facility with Staff M on April 16, 2014, between 08:00 AM and 04:00 PM it was observed that multiple rooms within the facility had power strips being used improperly or were installed improperly, and extension cords were in use in a permanent manner in multiple locations.

On April 16, 2014, between 08:00 AM and 04:00 PM an interview with Staff Member M revealed that staff had not noticed the power strips and extension cords referenced above.

These findings were confirmed by Staff M at the time of discovery.