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Based on observation and interview, the facility failed to provide 2-hour fire resistance rated occupancy separation in accordance with the requirements of NFPA 101, 2012 edition, Sections 18.1.3.3, 8.3.3.1, 8.3.3.3; NFPA 80, 2010 edition, Sections 5.2.13.1, 6.1.4.2.1. This deficient practice had the potential to affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include

On 08/06/2025 at 12:18 P.M., observation revealed that the 90-minute fire-rated door in the 2-hour fire-rated occupancy separation wall was propped open with a wooden wedge causing obstruction to free operation of door. The door was located in the Consult Room HN 1.A105 in the pharmacy.

The above finding was confirmed by interview with Staff DD (building services manager) and M4 (facilities system manager) at the time of discovery, and Staff A, NN, M, M5, YY, FF, R, XX, W, VV, WW, and Staff M2 and M3 in exit interview.

Based on observation, record review and interview, the facility failed to install one exterior door in accordance with NFPA 101, 2012 edition, Sections 18.2.1, 7.10.8.3.1. This deficient practice had the potential to affect all patients who receive care in Smoke Zone 2, and undetermined number of staff and visitors.

Findings include

On 08/05/2025 at 3:20 P.M., observation revealed that there was no "NO EXIT" sign posted on the exterior exit door of the Family Waiting Room HN 1.E151 adjacent to the Med-Surg Unit. The fully glazed door in the exterior wall was likely to be mistaken as an exit door.

The above finding was confirmed by interview with Staff DD (building services manager) and M4 (facilities system manager) at the time of discovery, and Staff A, NN, M, M5, YY, FF, R, XX, W, VV, WW, and Staff M2 and M3 in exit interview.

Based on observation, record review and staff interview, the facility failed to provide a properly installed and tested fire alarm system in accordance with the NFPA 101 2012 edition 18.3.4.1, 9.6.1.3, NFPA 72, 2010 edition, Sections 10.7.5, 10.12, 10.12.6, 14.4.5.22, 14.4.2.2(18)(b). This deficient practice had the potential to affect all patients, and undetermined number of staff and visitors in the facility.

Findings include

1. On 08/06/2025 between 1:30 and 3 P.M., interview with Staff DD (senior building services manager) revealed that the fire alarm main panel and three remote annunciator panels of the fire alarm system had been displaying trouble signals since the facility had started to replace the system from Banco to Johnson Controls (JCI) 6 to 9 months ago, and that there had been no change in display of signals. Staff DD further stated that main fire alarm control unit and remote annunciators did not display address of initiating device that activated or zone location of initiating device activating the alarm.

2. On 08/07/2025 between 8:55 A.M. and 9:05 A.M. observation revealed that the automatic dialer component of the facility fire alarm system, when placed in trouble by disconnecting the dedicated phone lines in the main fire alarm control unit located in the central utility plant room, did not annunciate a distinctive audible trouble signal nor a visible signal at the main fire alarm control panel (FACP). When interviewed on 08/07/2025 between 9 A.M. and 9:05 A.M, Staff M1 (electrical technician) stated that remote annunciator panels located in emergency department and two other locations, where the trouble signal is likely to be heard, did not annunciate visual and audible trouble signals.

When Staff M1 was asked on 08/07/25 at 9:51 A.M. whether the fire alarm remote supervising station received a trouble signal from the phone line disconnection test performed on 08/07/25 at 8:55 A.M, Staff M1 stated that the Banco company, who monitored the fire alarm system, did not receive trouble signals from the phone line failure test.

The above deficient practice was verified with Staff DD and M1 at the time of discovery.

Based on observation and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 99, 2012 edition, 10.2.3.6; NFPA 101, 2012 edition, Sections 18.5.1.1 and 9.1.2, and NFPA 70, 2011 edition, Sections 400.8, 590.2(B). This deficiency could affect an undetermined number of staff and patients receiving care in the facility.

Findings include

On 08/06/2025 at 10:36 A.M., observation in the Exam Room HN 1.F106 adjacent to stress testing room revealed that the power supply cord of the Plethysmograph equipment was plugged into a multi-outlet power strip device, and not into the wall receptacles in fixed wiring of building structure.

The above finding was confirmed by interview with Staff DD (building services manager) and M4 (facilities system manager) at the time of discovery, and Staff A, NN, M, M5, YY, FF, R, XX, W, VV, WW, and Staff M2 and M3 in exit interview.