HospitalInspections.org

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Operating room utility closet adjacent to room #4 hole in ceiling
Ceiling tile in lab room/ break room hole in ceiling.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
Cross corridor fire doors in birthing center near family wating area failed to latch.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to maintain the exit discharge free of obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
Oncology emergency lead to a wood gate swings inward with locking device that takes multiple motions to open.
Cross corridor fire doors floor 1 ramp in hallway blocked
Physical therapy emergency exit blocked.
Emergency exits shall be paved to a public way as follows:
Emergency room fast track exit
Emergency exit med surg
Emergency exit to central supply

The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon record review and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of a water supply problem to the fire sprinkler system and endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Manuel pull station across from central service blocked.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to conduct testing of the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The facility also failed maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility failed to maintain 18 inches of clearance in OR sterol supply .
The facility failed to has installed a fire lattice ceiling in sanctuary obstructing the sprinkler system.
5 year internal pipe testing required to be completed and documented

The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to ensure that hanging fabrics are rated as flame resistant. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Dressing room curtains in imaging area shall be fire rated.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/19/2015 between approximately 08:00 and 17:00 hours the facility has failed to properly humidity levels in operating rooms. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility failed to maintain relative humidly equal to or greater than 35% on 3/2/15 in operating room 1.
The above was discussed and acknowledged by the Chief Nursing Officer.

7.10.8.1 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT

Such sign shall have the word NO in letters 2 in high with a stroke width of 3/8 inch and the word EXIT in letters 1 inch high with the word EXIT below the word NO.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to properly distinguish Non exiting doors could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
The facility has failed to properly label door as not a exit near front entrance leading to pond.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Emergency generator shall have an emergency remote stop switch.
The above was discussed and acknowledged by the Chief Nursing Officer.

NFPA 110 1999 Edition 3-5.6 All level 1 and 2 installations shall have a remote manual stop station of a similar type to a break-glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building.

A-3-5.5.6 For level 1 and level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Managers office of oncology extension cord used as permanent wiring
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Digital imaging dance floor near phone ABHR directly over power strip.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Operating room utility closet adjacent to room #4 hole in ceiling
Ceiling tile in lab room/ break room hole in ceiling.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
Cross corridor fire doors in birthing center near family wating area failed to latch.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to maintain the exit discharge free of obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
Oncology emergency lead to a wood gate swings inward with locking device that takes multiple motions to open.
Cross corridor fire doors floor 1 ramp in hallway blocked
Physical therapy emergency exit blocked.
Emergency exits shall be paved to a public way as follows:
Emergency room fast track exit
Emergency exit med surg
Emergency exit to central supply

The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon record review and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of a water supply problem to the fire sprinkler system and endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Manuel pull station across from central service blocked.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to conduct testing of the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The facility also failed maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility failed to maintain 18 inches of clearance in OR sterol supply .
The facility failed to has installed a fire lattice ceiling in sanctuary obstructing the sprinkler system.
5 year internal pipe testing required to be completed and documented

The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to ensure that hanging fabrics are rated as flame resistant. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Dressing room curtains in imaging area shall be fire rated.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/19/2015 between approximately 08:00 and 17:00 hours the facility has failed to properly humidity levels in operating rooms. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility failed to maintain relative humidly equal to or greater than 35% on 3/2/15 in operating room 1.
The above was discussed and acknowledged by the Chief Nursing Officer.

7.10.8.1 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT

Such sign shall have the word NO in letters 2 in high with a stroke width of 3/8 inch and the word EXIT in letters 1 inch high with the word EXIT below the word NO.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to properly distinguish Non exiting doors could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
The facility has failed to properly label door as not a exit near front entrance leading to pond.
The above was discussed and acknowledged by the Chief Nursing Officer.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Emergency generator shall have an emergency remote stop switch.
The above was discussed and acknowledged by the Chief Nursing Officer.

NFPA 110 1999 Edition 3-5.6 All level 1 and 2 installations shall have a remote manual stop station of a similar type to a break-glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building.

A-3-5.5.6 For level 1 and level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based upon observations and staff interviews on 05/12/2015 between approximately 08:00 and 17:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Managers office of oncology extension cord used as permanent wiring
The above was discussed and acknowledged by the Chief Nursing Officer.