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Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency. This was evidenced by the following:
(A) Exit signage is obstructed from view in patient room corridor.
(B) Missing required exit sign in OB corridor and above west exit.
(C) Missing required exit signage in kitchen at west exit.
(D) Missing required exit signage inside OB at the west exit.

NFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner.

NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

The exit sign deficiencies were during the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 101, Sections 7.11.4, 7.11.5, and 7.11.6. At the time of the observation, the lab was using, storing and handling flammable liquids in the lab and the adjacent connected shell space thereby classifying the lab as a "High Hazard" per NFPA 101, Section 6.2.2.4. Failure to maintain the hazardous area in accordance with NFPA 101, Section 7.11 was evidenced by the following:

(A) Hospital Lab has only 1 (one) exit and is missing a required 2nd exit. The previously installed (and required) second exit from the space was occluded by recent construction leaving only one exit available for egress.

(B) Storage of combustibles is prohibited in the Lab shell space as the room exceeds 100 Sq ft, would be classified as a storage area, and does not have the required 1 hour protection rating required by NFPA 101 Table 18.3.2.1 for storage rooms greater than 100 sq. ft.

NFPA 101, 7.11.4 Not less than two means of egress shall be provided from each building or hazardous area thereof, unless all of the following criteria are met:
(1) Rooms or spaces do not exceed 200 ft2 (18.6 m2).
(2) Rooms or spaces have an occupant load not exceeding three persons.
(3) Rooms or spaces have a travel distance to the room door not exceeding 25 ft (7620 mm).

NFPA 101, 7.11.6 Doors serving high hazard contents areas with occupant loads in excess of five shall be permitted to be provided with a latch or lock only if the latch or lock is panic hardware or fire exit hardware complying with 7.2.1.7.

This deficiency has the potential to affect all occupants and staff within the lab and smoke compartment.
Both deficiencies were discussed during the survey and again during the exit conference conducted on January 2, 2020.

Based on observation during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 25 Sections 5.2.1.1.1, 4.1.4.1, and 5.2.1.2.

This was evidenced by the following:

(A) Wires and piping resting on top of fire sprinkler piping in supply chain hallway.
(B) Fire sprinklers are dirty in OR Recovery area.
(C) OR records room has shelving units that are too close to fire sprinklers. 18" of clearance from the sprinkler deflector is required.
(D) Wires are attached to fire sprinkler piping in med gas room.

NFPA 25, 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.

NFPA 25, 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

NFPA 25, 5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors. A.5.2.1.2 NFPA 13, Standard for the Installation of Sprinkler Systems, allows stock furnishings and equipment to be as close as 18 in. (457 mm) to standard spray sprinklers.

These deficiencies have the potential to affect occupants throughout all smoke compartment should the fire sprinkler system fail to perform as designed.

The Maintenance Director acknowledged the automatic sprinkler deficiencies during the tour of the facility.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 19.3.7.3 including 8.5.
This was evidenced by the following:
(A) Ceiling penetration in key room.
(B) Ceiling penetration in transfer switch electrical room.
(C) Wall penetration in med gas room.
(D) Rated door leading to lab has penetrations.

NFPA 101, Section 19.3.7.3, in part, smoke barrier walls constructed in accordance with Section 8.5 with a minimum of 1/2-hour fire resistive rating.

NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

The smoke barrier deficiencies have the potential to affect all residents, visitors, and staff within those smoke compartments.
These deficiencies were discussed during exit conference on January 2, 2020.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.1 and 4.7.4.
This was evidenced by the following:
(A) Fire drills were not conducted during varying times and conditions. NFPA 101, 4.7.4

NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual conditions that can occur in an actual emergency.
This deficiency was discussed with the Maintenance Director and the Administrator during exit conference on January 2, 2020.

Based on record review, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 99, 6.3.4.
This was evidenced by the following deficiencies:
(A) No records or documentation of the testing of hospital grade receptacles at patient bed locations and areas where deep sedation or general anesthesia is administered.

NFPA 99, 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
NFPA 99, 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.

This deficient practice could affect all occupants and staff through-out the facility if improper maintenance of electrical equipment causes a fire.

The Maintenance Director acknowledged the electrical deficiencies during record review. This deficiency was discussed during the exit conference conducted on January 2, 2020.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following:
(A) No records or documentation of generator battery monthly conductance testing.

NFPA 110, 8.3.7.1 The required monthly testing and recording of electrolyte specific gravity or conductance results (Reserve Capacity, "RC") of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required. The emergency power supply system provides power for emergency lighting.
Ref: 2012 NFPA 101 Section 21.2.9, 7.9.2.4, 4.6.12.1 / 2010 NFPA 110 Section 8.3.7.1

This deficiency has the potential to affect all occupants, which might include staff, residents, and visitors should the generator fail to start during an emergency.

This deficiency was discussed during the record review and again during the exit conference conducted on January 2, 2020.