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Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress, in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. In a fire emergency, this deficient practice could adversely affect 16 of 16 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/11/2014 between 8:30 AM and 1:30 PM, observation revealed corridor doors in the following locations did not positively latch into the door frames, because the doors were not equipped with positive latching hardware. Rather, the doors were equipped with single-key deadbolt locks, with thumb-turn devices on the egress side:
A). 2nd Floor, Room #1, OR, CSR, IV Supplies;
B). 2nd Floor, Paraslide Room;
C). 2nd Floor, private office;
D). First Floor, Procedure Room #2;
E). Basement level, three (3) doors leading into Dietary Department;
F). Basement level, Conference Room.

These findings were verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to document that all battery-operated emergency lights had been inspected/tested in each month of the prior year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000), Chapter 19, Section 19.2.9.1 and Chapter 7, Section 7.9.3. In a fire or other emergency, this deficient practice could adversely affect one (1) patient and all staff within the Operating Room.

FINDINGS INCLUDE:

On 06/11/2014 between 8:30 AM and 1:30 PM, during a review of available records provided by facility staff, no documentation could be provided verifying that the battery-operated emergency light located in the Operating Room had been inspected and tested during the previous year.

This finding was confirmed with the chief building engineer.

Based on observation and a staff interview, the facility failed to maintain one or more corridor doors in the means of egress, in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.3.6.3. In a fire emergency, this deficient practice could adversely affect 16 of 16 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/11/2014 between 8:30 AM and 1:30 PM, observation revealed corridor doors in the following locations did not positively latch into the door frames, because the doors were not equipped with positive latching hardware. Rather, the doors were equipped with single-key deadbolt locks, with thumb-turn devices on the egress side:
A). 2nd Floor, Room #1, OR, CSR, IV Supplies;
B). 2nd Floor, Paraslide Room;
C). 2nd Floor, private office;
D). First Floor, Procedure Room #2;
E). Basement level, three (3) doors leading into Dietary Department;
F). Basement level, Conference Room.

These findings were verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to document that all battery-operated emergency lights had been inspected/tested in each month of the prior year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000), Chapter 19, Section 19.2.9.1 and Chapter 7, Section 7.9.3. In a fire or other emergency, this deficient practice could adversely affect one (1) patient and all staff within the Operating Room.

FINDINGS INCLUDE:

On 06/11/2014 between 8:30 AM and 1:30 PM, during a review of available records provided by facility staff, no documentation could be provided verifying that the battery-operated emergency light located in the Operating Room had been inspected and tested during the previous year.

This finding was confirmed with the chief building engineer.

Based on observation and a staff interview, testing of the digital alarm communicator transmitter (DACT) had not been conducted during each month of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.6.1.4, and NFPA 70 (1999) and NFPA 72 (1999) and CMS policy. In a fire emergency, this deficient practice could adversely affect 16 of 16 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/11/2014 between 8:30 AM and 1:30 PM, during a review of available records provided by the chief building engineer, no documentation could be provided verifying the digital alarm communicator transmitter (DACT) was tested during the months of August and December of 2013, nor March and May of 2014.

This finding was confirmed with the chief building engineer.