HospitalInspections.org

Based on observation and interview, the facility failed to maintain a two hour fire barrier between the building and the tunnel that leads to a pipe tunnel that leads to the medical office building. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include

1. On 07/21/15 at 3:10 PM observation above the door in the barrier between the building and the tunnel that leads to a pipe tunnel that leads to the medical office building revealed an annular space around a copper line.

On 07/21/15 at 3:10 PM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 3:15 PM observation of the same barrier as seen above the drop down ceiling within the visiting nurse office revealed a penetration created by multiple wires and an annular space around a sprinkler line.

On 07/21/15 at 3:25 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the ratings of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 10:24 AM a tour was taken of the radiology area with Staff Q.

1. On 07/21/15 at 10:44 AM observation above the drop down ceiling of the two hour rated wall as seen from the passage leading directly to the computed tomography scanner revealed over the door leading from the passage a penetration over heating, ventilation and cooling ductwork.

On 07/21/15 at 10:44 AM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 11:11 AM observation above the drop down ceiling of the one hour rated wall on the south perimeter of the surgical waiting room near the radiology area revealed a 1.5 inch circle in the drywall with two red wires traveling out of it, a empty one inch hole next to that, a empty one inch square next to the empty circle, and to the far east a one inch elbow conduit that was open to air.

On 07/21/15 at 11:11 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 11:29 AM observation above the drop down ceiling of the one hour rated barrier between the operating room and occupational therapy room, as seen from the occupational therapy room, revealed a one inch square penetration with a corrugated conduit running through it.

On 07/21/15 at 11:29 AM in an interview, Staff Q confirmed the observation.

On 07/21/15 at 2:03 PM a tour was taken of the kitchen area with Staff Q

4. On 07/21/15 at 2:20 PM observation above the drop down ceiling of the one hour rated barrier of the west storage area, as seen from the corridor, revealed a one inch steel pipe with an annular space.

On 07/21/15 at 2:20 PM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 2:55 PM observation of the one hour barrier of the storage room near the mechanical space down the corridor from the kitchen, as seen from within storage room, revealed over the freezer blue, grey, and orange wires penetrating the barrier and creating an annular space.

On 07/21/15 at 2:55 PM in an interview, Staff Q confirmed the observation.

6. On 07/21/15 at 2:57 PM observation of the one hour barrier of the storage room near the mechanical space down the corridor from the kitchen, as seen from within storage room, revealed over the Christmas tree a four inch annular space around an old boiler line.

On 07/21/15 at 2:57 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure doors in smoke barriers either had self-closers or self closed completely. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

1. On 07/21/15 at 10:24 AM a tour was taken of the radiology area with Staff Q. At 10:35 AM observation of the only two hour rated barrier in the department revealed a door with a self closer and latching hardware. When tested, the self closer and latching hardware did not completely close the door.

On 07/21/15 at 10:35 AM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 11:15 AM observation of the door to the social worker ' s office (near the radiology area) and within a one hour barrier revealed it was not on a self closer.

On 07/21/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 11:21 AM observation of the double doors leading in the one hour barrier leading to the Benson wing revealed if the east door closes first, then both doors do not close and shut.

On 07/21/15 at 11:21 AM in an interview, Staff Q confirmed the observation.

4. On 07/21/15 at 1:58 PM a tour was taken of the basement of the building with Staff Q. On 07/21/15 at 1:58 PM observation of the door to the elevator equipment room revealed it was equipped with self-closing hardware. When tested, the hardware did not close the door.

On 07/23/15 at 1:58 PM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 3:25 PM observation of the information technology director ' s door in the one hour rated barrier in the basement revealed it did not have a self closer.

On 07/21/15 at 3:25 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each hazardous area was protected in accordance with 8.4, life safety code 101. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/22/15 at 1:35 PM a tour was taken of the building with Staff Q and M. At 2:00 PM observation of the biohazard room in suite 102 revealed it contained soiled linen. Observation of the room ' s door revealed it was not on a self-closer.

On 07/22/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure hazardous areas were provided with protective construction in accordance with section 8.4, life safety code 101. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 07/22/15 at 2:19 PM a tour was conducted of the facility with Staff Q and M. During the tour of the basement two furnaces were observed to be in the open without any protective construction.

During the tour of 07/22/15 at 2:19 PM in an interview, Staff Q confirmed the observation.

On 07/22/15 at 2:40 PM in the exam rooms area a room was observed to be full of medical records creating a hazardous space. The room did not have a door to it.

On 07/22/15 at 2:40 PM in an interview, Staff Q confirmed the room did not have a door.

Based on observation and interview, the facility failed to maintain the rated barriers of its hazardous areas, and failed to have sprinklers in a hazardous area. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R.

1. On 07/21/15 at 8:42 AM observation above the drop down ceiling of the one hour barrier that is the hazardous material storage room ' s south wall revealed over the door two plumbing lines with annular spaces.

On 07/21/15 at 8:42 AM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 8:45 AM observation above the drop down ceiling of the one hour barrier that is the hazardous material storage room ' s east wall revealed a plumbing line with an annular space.

On 07/21/15 at 8:45 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 9:00 AM observation above the drop down ceiling of the soiled utility room as seen from the corridor revealed it did not have a one hour rated barrier.

On 07/21/15 at 9:00 AM in an interview, Staff Q confirmed the observation.

4. On 07/21/15 at 9:01 AM observation above the drop down ceiling of the one hour barrier over the door to the clean utility room revealed a one inch white tipped conduit holding a grey and orange wire and open to air.

On 07/21/15 at 9:01 AM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 9:12 AM observation above the drop down ceiling as seen from within the clean utility room of the one hour rated barrier revealed over the door an elbow conduit holding grey wires and open to air.

On 07/21/15 at 9:12 AM in an interview, Staff Q confirmed the observation.

6. On 07/21/15 at 9:16 AM observation above the drop down ceiling of the north/south one hour barrier between the clean utility room and soiled utility room revealed an open three inch conduit.

On 07/21/15 at 9:16 AM in an interview, Staff Q confirmed the observation.

7. On 07/21/15 at 9:32 AM observation of the radiology room revealed it contained shelving that ran the length of the northern wall and was packed with radiology records. The room was not sprinklered.

On 07/21/15 at 9:32 AM in an interview, Staff Q confirmed the room did not have sprinklers.

Based on observation and interview, the facility failed to maintain the rating of barriers surrounding hazardous areas, and failed to ensure each hazardous area was surrounded with either one hour fire rated construction or had an approved automatic fire extinguishing system and smoke resisting partitions and doors. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 2:03 PM a tour was taken of the kitchen area with Staff Q.

1. On 07/21/15 at 2:26 PM observation above the drop down ceiling of the one hour rated barrier in the soiled linen room across from the kitchen revealed in the west wall an open one inch elbow conduit holding a grey wire and over the door a half inch conduit holding two red wires.

On 07/21/15 at 2:26 PM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 2:35 PM observation above the drop down ceiling of the one hour rated barrier over the door and outside the soiled linen room across from the kitchen revealed a one inch open conduit holding two red wires, one open straight conduit holding four wires, and a open half inch conduit with a white tip holding a brown wire.

On 07/21/15 at 2:35 PM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 2:52 PM observation of the one hour rated barrier between the soiled linen room between it and a mechanical space, as seen from the mechanical space, revealed a one inch circular penetration and two six inch sprinkler lines with an annular space above them.

On 07/21/15 at 2:52 PM in an interview, Staff Q confirmed the observation.

4. On 07/22/15 at 11:30 AM a tour was taken of the laboratory area. The laboratory area was observed to not have any sprinklers.

On 07/22/15 at 12:06 PM observation above the drop down ceiling of the northern end of the barrier between the laboratory and the corridor revealed it consisted of one layer of drywall over the door.

On 07/22/15 at 12:06 PM in an interview, Staff Q confirmed the observation.

5. On 07/22/15 at 12:15 PM observation above the drop down ceiling of the southern end of the barrier between the laboratory and the corridor revealed it also consisted of one layer of drywall over the door.

On 07/22/15 at 12:15 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to have each path of egress marked within the medical office building. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

1. On 07/22/15 at 1:35 PM a tour was taken of the building with Staff Q and M. At 1:35 PM observation of suite 105 revealed an evacuation plan hanging in the waiting room. Review of the plan revealed a path of egress down the hall from the waiting area and discharged out a side back door. Observation of the hall did not reveal any exit signage showing this path of egress.

On 07/22/15 at 1:35 PM in an interview, Staff Q confirmed the observation.

2. On 07/22/15 at 1:50 PM observation of suite 104 revealed an evacuation plan in the waiting area revealing a path of egress down the hall, through an exam room, and discharges out the back door. Observation of the path of egress revealed the exit sign over the exit discharge door could not been seen when the exam room door is closed. (An exit sign over the exam room door also was not observed.)

On 07/22/15 at 1:50 PM in an interview, Staff Q confirmed the observation.

Based on record review and interview, the facility failed to ensure it had an automatic sprinkler system installed in accordance with National Fire Protection Association 13 to provide complete coverage of all portions of the facility. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

Review of a building permit from the Ohio Department of Commerce for plan number 200570495, described as " emergency department addition " was completed on 07/23/15.

Review of an occupancy permit from the Ohio Department of Commerce for plan number 200570495 was completed on 07/23/15. The review revealed the permit was approved on 01/30/06 and also stated the construction type was 1 B, i.e., I (332), and the use group as I-2.

A review of the Ohio Administrative Code 4101:1-3-01, Use and occupancy classification, was completed on 07/23/15. The review revealed group I-2 is a hospital, and it defines a hospital as, " buildings or portions thereof used on a 24-hour basis for the medical, psychiatric, obstetrical or surgical treatment of inpatients who are incapable of self-preservation. "

On 07/23/15 a review of the facility ' s schematic was completed. The review revealed a two hour west/east barrier separating the emergency department area from the rest of the campus.

The review revealed 11 rooms, including a room used for sleep studies (i.e. a room for a sleeping patient), was not sprinklered.

On 07/21/15 in an interview, Staff Q stated patients use the sleep laboratory from 9:00 PM to 6:00 AM.

On 07/20/15 at 2:30 PM in an interview, Staff Q stated whole area to the north of the two hour barrier is 14, 926 square feet, with about 11,000 square feet of that new construction.

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R. Observation of the 11 rooms, including the sleep study room, and an outside canvas canopy 28 feet long and 8 feet wide, confirmed they were not sprinklered.

Based on observation and interview, the facility failed to ensure its sprinkler system was maintained in a reliable operating condition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 3:30 PM observation of the medical records room revealed was sprinklered. However, within the room were computer boxes stacked in the middle of the room to less than 18 inches from the sprinkler heads.

On 07/21/15 at 3:30 PM in an interview, Staff Q confirmed the observation.

Based on observation, interview, and record review, the facility failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 2-3.2, and have gauges inspected or replaced every five years, and failed to maintain its sprinkler heads free of dust. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

1. A review of the facility's fire sprinkler inspection reports was completed on 07/23/15. The review revealed the last annual inspection of the system was completed on 11/26/14. The inspection report stated the last time the gauges were tested or replaced was in 1992.

On 07/23/15 at 11:29 AM in an interview, the finding was presented to Staff Q.

On 07/23/15 at 4:15 PM at exit, no additional information was provided regarding inspection report.

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R.

2. On 07/21/15 at 8:50 AM observation of the sprinkler heads by the supply vents in both trauma rooms revealed the bulbs were coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 8:50 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 8:53 AM observation of the sprinkler heads by the supply vents in the physician area and the physician sleep room bathroom and in the corridor outside the physician area revealed the bulbs were coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:48 AM observation of the sprinkler head in the bathroom in the waiting area revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:48 AM in an interview, Staff Q confirmed the observations.

4. On 07/21/15 at 9:50 AM observation of the sprinkler head by the vent by the TV in the waiting area revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:50 AM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 9:52 AM observation of the sprinkler head in the blood draw room revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:52 AM in an interview, Staff Q confirmed the observation.

6. On 07/21/15 at 9:57 AM observation of the sprinkler head in the occupation health area revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:57 AM in an interview, Staff Q confirmed the observation.

7. On 07/21/15 at 10:01 AM observation of the sprinkler heads in exam rooms three, four, and five, and by the security monitors by the nursing station, and in the corridor outside rooms eight and nine revealed the bulbs were coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 10:01 AM in an interview, Staff Q confirmed the observation.

8. On 07/21/15 at 4:03 PM sidewall mounted sprinkler heads were observed mounted along the ambulance bay.

On 07/21/15 at 3:37 PM observation of the inventory of spare sprinkler heads at the sprinkler riser did not reveal any spare sidewall mounted sprinkler heads.

On 07/21/15 at 4:03 PM in an interview, Staff Q confirmed he/she did not have any sidewall mounted heads.

Based on observation, interview, and record review, the facility failed to maintain a water supply which provided continuous and adequate pressure. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

A review of the facility's fire sprinkler inspection reports was completed on 07/23/15. The review revealed the last annual inspection of the system was completed on 11/26/14. The inspection report stated during the main drain test the flow pressure 25 psi.

On 07/21/15 at 3:37 PM an observation of the sprinkler riser room was conducted with Staff Q. Observed by the spare sprinkler head box (and not on the sprinkler system itself) was a hydraulic nameplate that stated the residual pressure needed to be 37.9 psi. Therefore, the system had a residual reading 12.9 PSI below the minimum required.

On 07/23/15 at 10:00 AM the finding was presented to Staff Q.

On 07/23/15 at 11:29 AM Staff Q presented an email dated 07/23/15 at 11:25 AM that did not state the inspector compared the results of the main drain test to the requirements listed on the hydraulic nameplate.

19.2.5.7
Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2 (930 m2


Based on record review and interview, the facility failed to ensure its emergency area suite was less than 10000 square feet. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/23/15 at 3:45 PM in an interview, both Staff Q and S stated the emergency room area is considered to be a suite. Both confirmed the square footage to be 14,926 square feet, with about 11,000 square feet new construction. They both confirmed the area is not fully sprinklered.

On 07/23/15 a review of the facility's schematic was completed. The review revealed 11 rooms, including a room used for sleep studies (i.e. a room for a sleeping patient), was not sprinklered.

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R. Observation of the 11 rooms confirmed they were not sprinklered.

Based on interview, the facility failed to have its Essential Electrical System divided into an emergency system and an equipment system. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/23/15 at 12:15 PM in an interview, Staff Q explained when electrical power is lost from the electric company, the generator simultaneously provides electricity to both the emergency system and equipment system. He/she explained the generator is arranged to pick up the load of both simultaneously because there is not much equipment to run.

On 07/23/15 at 3:12 PM in an interview, Staff R confirmed the hospital's Essential Electrical System is not divided into an emergency system and an equipment system.

Based on observation and interview, the facility failed to maintain a two hour fire barrier between the building and the tunnel that leads to a pipe tunnel that leads to the medical office building. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include

1. On 07/21/15 at 3:10 PM observation above the door in the barrier between the building and the tunnel that leads to a pipe tunnel that leads to the medical office building revealed an annular space around a copper line.

On 07/21/15 at 3:10 PM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 3:15 PM observation of the same barrier as seen above the drop down ceiling within the visiting nurse office revealed a penetration created by multiple wires and an annular space around a sprinkler line.

On 07/21/15 at 3:25 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the ratings of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 10:24 AM a tour was taken of the radiology area with Staff Q.

1. On 07/21/15 at 10:44 AM observation above the drop down ceiling of the two hour rated wall as seen from the passage leading directly to the computed tomography scanner revealed over the door leading from the passage a penetration over heating, ventilation and cooling ductwork.

On 07/21/15 at 10:44 AM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 11:11 AM observation above the drop down ceiling of the one hour rated wall on the south perimeter of the surgical waiting room near the radiology area revealed a 1.5 inch circle in the drywall with two red wires traveling out of it, a empty one inch hole next to that, a empty one inch square next to the empty circle, and to the far east a one inch elbow conduit that was open to air.

On 07/21/15 at 11:11 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 11:29 AM observation above the drop down ceiling of the one hour rated barrier between the operating room and occupational therapy room, as seen from the occupational therapy room, revealed a one inch square penetration with a corrugated conduit running through it.

On 07/21/15 at 11:29 AM in an interview, Staff Q confirmed the observation.

On 07/21/15 at 2:03 PM a tour was taken of the kitchen area with Staff Q

4. On 07/21/15 at 2:20 PM observation above the drop down ceiling of the one hour rated barrier of the west storage area, as seen from the corridor, revealed a one inch steel pipe with an annular space.

On 07/21/15 at 2:20 PM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 2:55 PM observation of the one hour barrier of the storage room near the mechanical space down the corridor from the kitchen, as seen from within storage room, revealed over the freezer blue, grey, and orange wires penetrating the barrier and creating an annular space.

On 07/21/15 at 2:55 PM in an interview, Staff Q confirmed the observation.

6. On 07/21/15 at 2:57 PM observation of the one hour barrier of the storage room near the mechanical space down the corridor from the kitchen, as seen from within storage room, revealed over the Christmas tree a four inch annular space around an old boiler line.

On 07/21/15 at 2:57 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure doors in smoke barriers either had self-closers or self closed completely. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

1. On 07/21/15 at 10:24 AM a tour was taken of the radiology area with Staff Q. At 10:35 AM observation of the only two hour rated barrier in the department revealed a door with a self closer and latching hardware. When tested, the self closer and latching hardware did not completely close the door.

On 07/21/15 at 10:35 AM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 11:15 AM observation of the door to the social worker ' s office (near the radiology area) and within a one hour barrier revealed it was not on a self closer.

On 07/21/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 11:21 AM observation of the double doors leading in the one hour barrier leading to the Benson wing revealed if the east door closes first, then both doors do not close and shut.

On 07/21/15 at 11:21 AM in an interview, Staff Q confirmed the observation.

4. On 07/21/15 at 1:58 PM a tour was taken of the basement of the building with Staff Q. On 07/21/15 at 1:58 PM observation of the door to the elevator equipment room revealed it was equipped with self-closing hardware. When tested, the hardware did not close the door.

On 07/23/15 at 1:58 PM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 3:25 PM observation of the information technology director ' s door in the one hour rated barrier in the basement revealed it did not have a self closer.

On 07/21/15 at 3:25 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each hazardous area was protected in accordance with 8.4, life safety code 101. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/22/15 at 1:35 PM a tour was taken of the building with Staff Q and M. At 2:00 PM observation of the biohazard room in suite 102 revealed it contained soiled linen. Observation of the room ' s door revealed it was not on a self-closer.

On 07/22/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure hazardous areas were provided with protective construction in accordance with section 8.4, life safety code 101. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 07/22/15 at 2:19 PM a tour was conducted of the facility with Staff Q and M. During the tour of the basement two furnaces were observed to be in the open without any protective construction.

During the tour of 07/22/15 at 2:19 PM in an interview, Staff Q confirmed the observation.

On 07/22/15 at 2:40 PM in the exam rooms area a room was observed to be full of medical records creating a hazardous space. The room did not have a door to it.

On 07/22/15 at 2:40 PM in an interview, Staff Q confirmed the room did not have a door.

Based on observation and interview, the facility failed to maintain the rated barriers of its hazardous areas, and failed to have sprinklers in a hazardous area. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R.

1. On 07/21/15 at 8:42 AM observation above the drop down ceiling of the one hour barrier that is the hazardous material storage room ' s south wall revealed over the door two plumbing lines with annular spaces.

On 07/21/15 at 8:42 AM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 8:45 AM observation above the drop down ceiling of the one hour barrier that is the hazardous material storage room ' s east wall revealed a plumbing line with an annular space.

On 07/21/15 at 8:45 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 9:00 AM observation above the drop down ceiling of the soiled utility room as seen from the corridor revealed it did not have a one hour rated barrier.

On 07/21/15 at 9:00 AM in an interview, Staff Q confirmed the observation.

4. On 07/21/15 at 9:01 AM observation above the drop down ceiling of the one hour barrier over the door to the clean utility room revealed a one inch white tipped conduit holding a grey and orange wire and open to air.

On 07/21/15 at 9:01 AM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 9:12 AM observation above the drop down ceiling as seen from within the clean utility room of the one hour rated barrier revealed over the door an elbow conduit holding grey wires and open to air.

On 07/21/15 at 9:12 AM in an interview, Staff Q confirmed the observation.

6. On 07/21/15 at 9:16 AM observation above the drop down ceiling of the north/south one hour barrier between the clean utility room and soiled utility room revealed an open three inch conduit.

On 07/21/15 at 9:16 AM in an interview, Staff Q confirmed the observation.

7. On 07/21/15 at 9:32 AM observation of the radiology room revealed it contained shelving that ran the length of the northern wall and was packed with radiology records. The room was not sprinklered.

On 07/21/15 at 9:32 AM in an interview, Staff Q confirmed the room did not have sprinklers.

Based on observation and interview, the facility failed to maintain the rating of barriers surrounding hazardous areas, and failed to ensure each hazardous area was surrounded with either one hour fire rated construction or had an approved automatic fire extinguishing system and smoke resisting partitions and doors. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 2:03 PM a tour was taken of the kitchen area with Staff Q.

1. On 07/21/15 at 2:26 PM observation above the drop down ceiling of the one hour rated barrier in the soiled linen room across from the kitchen revealed in the west wall an open one inch elbow conduit holding a grey wire and over the door a half inch conduit holding two red wires.

On 07/21/15 at 2:26 PM in an interview, Staff Q confirmed the observation.

2. On 07/21/15 at 2:35 PM observation above the drop down ceiling of the one hour rated barrier over the door and outside the soiled linen room across from the kitchen revealed a one inch open conduit holding two red wires, one open straight conduit holding four wires, and a open half inch conduit with a white tip holding a brown wire.

On 07/21/15 at 2:35 PM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 2:52 PM observation of the one hour rated barrier between the soiled linen room between it and a mechanical space, as seen from the mechanical space, revealed a one inch circular penetration and two six inch sprinkler lines with an annular space above them.

On 07/21/15 at 2:52 PM in an interview, Staff Q confirmed the observation.

4. On 07/22/15 at 11:30 AM a tour was taken of the laboratory area. The laboratory area was observed to not have any sprinklers.

On 07/22/15 at 12:06 PM observation above the drop down ceiling of the northern end of the barrier between the laboratory and the corridor revealed it consisted of one layer of drywall over the door.

On 07/22/15 at 12:06 PM in an interview, Staff Q confirmed the observation.

5. On 07/22/15 at 12:15 PM observation above the drop down ceiling of the southern end of the barrier between the laboratory and the corridor revealed it also consisted of one layer of drywall over the door.

On 07/22/15 at 12:15 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to have each path of egress marked within the medical office building. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

1. On 07/22/15 at 1:35 PM a tour was taken of the building with Staff Q and M. At 1:35 PM observation of suite 105 revealed an evacuation plan hanging in the waiting room. Review of the plan revealed a path of egress down the hall from the waiting area and discharged out a side back door. Observation of the hall did not reveal any exit signage showing this path of egress.

On 07/22/15 at 1:35 PM in an interview, Staff Q confirmed the observation.

2. On 07/22/15 at 1:50 PM observation of suite 104 revealed an evacuation plan in the waiting area revealing a path of egress down the hall, through an exam room, and discharges out the back door. Observation of the path of egress revealed the exit sign over the exit discharge door could not been seen when the exam room door is closed. (An exit sign over the exam room door also was not observed.)

On 07/22/15 at 1:50 PM in an interview, Staff Q confirmed the observation.

Based on record review and interview, the facility failed to ensure it had an automatic sprinkler system installed in accordance with National Fire Protection Association 13 to provide complete coverage of all portions of the facility. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

Review of a building permit from the Ohio Department of Commerce for plan number 200570495, described as " emergency department addition " was completed on 07/23/15.

Review of an occupancy permit from the Ohio Department of Commerce for plan number 200570495 was completed on 07/23/15. The review revealed the permit was approved on 01/30/06 and also stated the construction type was 1 B, i.e., I (332), and the use group as I-2.

A review of the Ohio Administrative Code 4101:1-3-01, Use and occupancy classification, was completed on 07/23/15. The review revealed group I-2 is a hospital, and it defines a hospital as, " buildings or portions thereof used on a 24-hour basis for the medical, psychiatric, obstetrical or surgical treatment of inpatients who are incapable of self-preservation. "

On 07/23/15 a review of the facility ' s schematic was completed. The review revealed a two hour west/east barrier separating the emergency department area from the rest of the campus.

The review revealed 11 rooms, including a room used for sleep studies (i.e. a room for a sleeping patient), was not sprinklered.

On 07/21/15 in an interview, Staff Q stated patients use the sleep laboratory from 9:00 PM to 6:00 AM.

On 07/20/15 at 2:30 PM in an interview, Staff Q stated whole area to the north of the two hour barrier is 14, 926 square feet, with about 11,000 square feet of that new construction.

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R. Observation of the 11 rooms, including the sleep study room, and an outside canvas canopy 28 feet long and 8 feet wide, confirmed they were not sprinklered.

Based on observation and interview, the facility failed to ensure its sprinkler system was maintained in a reliable operating condition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/21/15 at 3:30 PM observation of the medical records room revealed was sprinklered. However, within the room were computer boxes stacked in the middle of the room to less than 18 inches from the sprinkler heads.

On 07/21/15 at 3:30 PM in an interview, Staff Q confirmed the observation.

Based on observation, interview, and record review, the facility failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 2-3.2, and have gauges inspected or replaced every five years, and failed to maintain its sprinkler heads free of dust. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

1. A review of the facility's fire sprinkler inspection reports was completed on 07/23/15. The review revealed the last annual inspection of the system was completed on 11/26/14. The inspection report stated the last time the gauges were tested or replaced was in 1992.

On 07/23/15 at 11:29 AM in an interview, the finding was presented to Staff Q.

On 07/23/15 at 4:15 PM at exit, no additional information was provided regarding inspection report.

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R.

2. On 07/21/15 at 8:50 AM observation of the sprinkler heads by the supply vents in both trauma rooms revealed the bulbs were coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 8:50 AM in an interview, Staff Q confirmed the observation.

3. On 07/21/15 at 8:53 AM observation of the sprinkler heads by the supply vents in the physician area and the physician sleep room bathroom and in the corridor outside the physician area revealed the bulbs were coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:48 AM observation of the sprinkler head in the bathroom in the waiting area revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:48 AM in an interview, Staff Q confirmed the observations.

4. On 07/21/15 at 9:50 AM observation of the sprinkler head by the vent by the TV in the waiting area revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:50 AM in an interview, Staff Q confirmed the observation.

5. On 07/21/15 at 9:52 AM observation of the sprinkler head in the blood draw room revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:52 AM in an interview, Staff Q confirmed the observation.

6. On 07/21/15 at 9:57 AM observation of the sprinkler head in the occupation health area revealed the bulb was coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 9:57 AM in an interview, Staff Q confirmed the observation.

7. On 07/21/15 at 10:01 AM observation of the sprinkler heads in exam rooms three, four, and five, and by the security monitors by the nursing station, and in the corridor outside rooms eight and nine revealed the bulbs were coated in dust such that the fluid within the bulb was difficult to see.

On 07/21/15 at 10:01 AM in an interview, Staff Q confirmed the observation.

8. On 07/21/15 at 4:03 PM sidewall mounted sprinkler heads were observed mounted along the ambulance bay.

On 07/21/15 at 3:37 PM observation of the inventory of spare sprinkler heads at the sprinkler riser did not reveal any spare sidewall mounted sprinkler heads.

On 07/21/15 at 4:03 PM in an interview, Staff Q confirmed he/she did not have any sidewall mounted heads.

Based on observation, interview, and record review, the facility failed to maintain a water supply which provided continuous and adequate pressure. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

A review of the facility's fire sprinkler inspection reports was completed on 07/23/15. The review revealed the last annual inspection of the system was completed on 11/26/14. The inspection report stated during the main drain test the flow pressure 25 psi.

On 07/21/15 at 3:37 PM an observation of the sprinkler riser room was conducted with Staff Q. Observed by the spare sprinkler head box (and not on the sprinkler system itself) was a hydraulic nameplate that stated the residual pressure needed to be 37.9 psi. Therefore, the system had a residual reading 12.9 PSI below the minimum required.

On 07/23/15 at 10:00 AM the finding was presented to Staff Q.

On 07/23/15 at 11:29 AM Staff Q presented an email dated 07/23/15 at 11:25 AM that did not state the inspector compared the results of the main drain test to the requirements listed on the hydraulic nameplate.

19.2.5.7
Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2 (930 m2


Based on record review and interview, the facility failed to ensure its emergency area suite was less than 10000 square feet. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/23/15 at 3:45 PM in an interview, both Staff Q and S stated the emergency room area is considered to be a suite. Both confirmed the square footage to be 14,926 square feet, with about 11,000 square feet new construction. They both confirmed the area is not fully sprinklered.

On 07/23/15 a review of the facility's schematic was completed. The review revealed 11 rooms, including a room used for sleep studies (i.e. a room for a sleeping patient), was not sprinklered.

On 07/21/15 at 8:30 AM a tour was taken of the emergency department with Staff Q and R. Observation of the 11 rooms confirmed they were not sprinklered.

Based on interview, the facility failed to have its Essential Electrical System divided into an emergency system and an equipment system. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of one patient at the time of the survey.

Findings include:

On 07/23/15 at 12:15 PM in an interview, Staff Q explained when electrical power is lost from the electric company, the generator simultaneously provides electricity to both the emergency system and equipment system. He/she explained the generator is arranged to pick up the load of both simultaneously because there is not much equipment to run.

On 07/23/15 at 3:12 PM in an interview, Staff R confirmed the hospital's Essential Electrical System is not divided into an emergency system and an equipment system.