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Based on observation and interview, the facility failed to provide illumination of exit discharges from 3 of 8 exits in accordance with NFPA 101 (2012 edition) 19.2.8, 7.8.1.4. This deficiency had the potential to affect all patients, and undetermined number of staff and visitors in the facility.

Findings include

1. On 08/26/22 between 8:45 am and 9:20 am, observation revealed that the exit discharge from Exit Door #6 adjacent to the Storage D98 was illuminated with a light fixture that did not have two lamps, nor was the exit illuminated with two separate normal power light fixtures.
2. On 08/26/22 between 8:45 am and 9:20 am, observation revealed that the exit discharge from Exit Door #5 adjacent to the Patient Room D82 was illuminated with a light fixture that did not have two lamps, nor was the exit illuminated with two separate normal power light fixtures.
3. On 08/26/22 between 8:45 am and 9:20 am, observation revealed that the exit discharge from Exit Door #3 adjacent to the Patient Room D58 was illuminated with a light fixture that did not have two lamps, nor was the exit illuminated with two separate normal power light fixtures.

The above deficiency was confirmed by interview with Staff M1 at the time of discovery, and with Staff J, Staff K, and Staff A on 08/26/22 at 10:45 am.

Based on observation and interview, the facility failed to provide emergency illumination in (i) one suite passage, and (ii) exit discharges from 2 of 8 exits in accordance with NFPA 101 (2012 edition) 19.2.9.1, 7.9. This deficiency had the potential to affect all patients, undetermined number of staff and visitors in the facility.

Findings include

1. On 08/25/22 at 3:30 pm, observation revealed that the CT hallway serving CT Room, Endoscopy C58, and Ultrasound Room C74 did not have emergency lighting, or the switch controlling emergency lighting was switched off. The emergency light fixture cannot be switched off.

2. On 08/26/22 between 8:45 am and 9:30 am, observation revealed that exit discharges from Exit Door #5 adjacent to the Patient Room D82, and Exit Door #6 adjacent to Storage D98, on the 1st Floor did not have emergency lighting.

The above deficiency was confirmed by interview with Staff M1 at the time of discovery, and with Staff J, Staff K, and Staff A on 08/26/22 at 10:45 am.

Based on observation and interview, the facility failed to protect one hazardous area with smoke partition in accordance with NFPA 101 19.3.2.1, 8.4.3.5. The deficient practice affected all patients who receive care in the Computer Tomography (CT) and Ultrasound Suite.

Findings include

On 08/24/22 at 4:35 pm, observation revealed that there was no self-closing device on the solid-core wood door that protected an opening in the wall of Storage C94 with combustibles. The room is located in CT and Ultrasound Suite on the 1st Floor.

The above finding was confirmed by interview with Staff J, Staff K and Staff M1 at the time of discovery, and with Staff A on 08/26/22 at 10:45 am.

Based on observation and interview, the facility failed to properly install and test the fire alarm system in accordance with the NFPA 101, 2012 edition 19.3.4.1, 9.6.1.3, NFPA 72, 2010 edition 10.7.5, 10.12.5, 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 08/25/22 between 2:07 PM and 2:15 PM, observation revealed that the automatic dialer component, Digital Alarm Communicator Transmitter (DACT), of the facility fire alarm system, when placed in trouble by disconnecting the dedicated phone line in the automatic dialer, did not annunciate distinctive audible and visible trouble signals at the remote annunciator panel located in the Nurse Station on 1st Floor. The fire alarm automatic dialer equipment installed in 2003 was located in the Mechanical Room B31.

The above deficiency was confirmed by interview with Staff M1 and Staff K at the time of discovery, and by phone interview with Staff J and Staff A on 08/29/22 at 12 PM.

Based on observation and interview, the facility did not properly install the building sprinkler system in accordance with NFPA 101 19.3.5.3, 9.7.1.1, NFPA 13, 2010 edition, 8.3.3.2. The deficient practice had a potential to affect all patients who receive care in the basement.

Findings include
1. On 08/24/22 at 10:15 am, observation revealed that all sprinkler heads were not quick-response in the Mechanical Room B31, which is considered one compartment. The same compartment cannot have a mix of quick response and standard response sprinkler heads.

2. On 08/24/22 at 11:07 am, observation revealed that all sprinkler heads were not quick-response in the Boiler Room A47, which is considered one compartment. The same compartment cannot have a mix of quick response and standard response sprinkler heads.

3. On 08/24/22 at 11:24 am, observation revealed that all sprinkler heads were not quick-response in the Clean Storage Room B25, which is considered one compartment. The same compartment cannot have a mix of quick response and standard response sprinkler heads.

The above findings were confirmed by interview with Staff J, Staff K and Staff M1 at the time of discovery, and with Staff A on 08/26/22 at 10:45 am.

Based on observation and interview, the facility failed to separate one corridor from other spaces in accordance with the NFPA 101, 2012 edition 19.3.6.1(7), 19.3.4.1, 9.6.1.3, NFPA 72, 2010 edition 17.7.1.8. This deficient practice had the potential to affect all patients, and undetermined number of staff and visitors in the facility.

Findings include:

On 08/24/22 at 3:07 pm, observation revealed that the ceiling-mounted smoke detector installed in the Patient Lounge D126, which was open to corridor, was within 2 feet of heating, ventilating, and air conditioning (HVAC) supply air diffuser. There was no evidence available at the time of survey that the air velocity at the smoke detector was less than or equal to 300 feet per minute.

The above deficiency was confirmed by interview with Staff J, Staff K and Staff M1 at the time of discovery, and with Staff A on 08/26/22 at 10:45 am.

Based on observation and interview, the facility failed to provide a compliant Heating, Ventilating and Air Conditioning System (HVAC) system due to lack of duct smoke detector in one Air Handling Unit HVAC duct in accordance with NFPA 101 19.5.2.1, 9.2.1, NFPA 90A 6.4.2.1, 6.4.3.1. The deficient practice affected all patients who receive care in the areas served by the HVAC system unit.

Findings include

On 08/24/22 between 10:20 am and 10:45 am, observation revealed that there was no duct smoke detector installed in the main supply air duct of the air handling unit, AC #2, to intercept smoke in supply duct and subsequently shutdown the unit fan. The air handling unit serving the facility had a fan capacity of more than 2000 cfm, and was located in the Mechanical Room B31.

The above finding was confirmed by interview with Staff M1 at the time of discovery, and with Staff J, Staff K and Staff A on 08/26/22 at 10:45 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of clear working space in front of electrical equipment and switches in accordance with NFPA 101 19.5.1, 9.1.2, NFPA 70 110.34(A). The deficiency had the potential to affect all patients and undetermined number of staff in the facility.

Findings include

On 08/24/22 at 11:07 am, observation revealed that the working space provided in front of an automatic transfer switch equipment and disconnect switch located in the Boiler Room in the basement was less than 36 inches. The clear space between a cart with pipe bends stored in front of the equipment and switch, and the equipment was measured to be 29 inches.

The above deficiency was confirmed by interview with Staff J, Staff K and Staff M1 at the time of discovery, and with Staff A on 08/26/22 at 10:45 am.