HospitalInspections.org

Based on observation and interview, the facility failed to provide a level walking surface in the path of egress in accordance with the requirements of NFPA 101 (2012 edition), 7.1.6 and 7.1.7. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 6/14/18 at 2:55 PM, observation revealed in the exit discharge path from the 500 wing exit door that there was a 1/2" grade change on the both ends of a concrete slab in the exit discharge path.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview, the facility failed to provide protection of the vertical shaft opening in accordance with NFPA 101 (2012 edition); 19.3.1, 8.6., and 8.6.2. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

FINDINGS INCLUDE:

On 06/14/18 at 2:30 PM, observation revealed in the lower level mechanical room that there was a 2 inch wide unselaed gap around a air duct penetration into a fire rated vertical shaft wall.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview, the facility failed to provide a visible and audible fire-alarm notification device as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition), Sections 18.6. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 6/19/2018 at 11:35 am, observation revealed that the visible fire alarm notification devices were not provided inside the upper level floor OR on-call room.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview, the facility failed to provide a visible and audible fire-alarm notification devices as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition), Sections 18.6. These deficiencies had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

1. On 6/14/2018 at 2:00 PM, observation revealed that the visible fire alarm notification devices were not provided inside the lower level floor men's locker room.

2. On 6/14/2018 at 2:05 PM, observation revealed that the visible fire alarm notification devices were not provided inside the lower level floor women's locker room.

3. On 6/14/2018 at 2:35 PM, observation revealed that the visible fire alarm notification devices were not provided inside the upper level floor emergency department on-call room.

4. On 6/14/2018 at 2:35 PM, observation revealed that the visible fire alarm notification devices were not provided inside the upper level floor employee break room.

These deficient practices were confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview, the facility did not provide a sprinkler system with no obstructions near the sprinkler head in accordance with NFPA 101 (2012 ed.), 19.3.5.3 and NFPA 13 (2010 ed.), 8.6.5.2.1.1 (Table 8.6.5.2.1), 8.6.5.2.2 and 8.6.5.2.2.1. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

FINDINGS INCLUDE:

On 6/19/2018 at 11:45 am, observation revealed on the first floor doctor's locker room bathroom, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to other side of the curtain.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, and NFPA 25 - 2011 edition, Sections 5.2.1, and 5.2.1.1.1. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 6/14/2018 at 1:55 PM, observation revealed in the lower level Kitchen Freezer Room that the sprinkler head had lint and other foreign materials on it.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 5.2.1. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 06/19/18 at 11:15 am, observation revealed in the upper level emergency department storage room that there were 5 unsealed holes in the ceiling. These holes did not duplicate the tight conditions that were used in the sprinkler UL certification test.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on record review and interview, the facility failed to inspect the portable fire extinguishers as required by NFPA 101 (2012 edition), Sections 19.3.5.12 and 9.7.4.1, and NFPA 10 (2010 edition) Sections 7.2.1.2, 7.2.2 & 7.2.2.2. These deficiencies had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

1. On 06/14/2018 at 12:55 PM, during review of the facility monthly portable fire extinguishers inspection records it was discovered that the facility did not inspect the obstructions to access or visibility for the fire extinguishers every month within the last year.

2. On 06/14/2018 at 12:56 PM, during review of the facility monthly portable fire extinguishers inspection records it was discovered that the facility did not determine the fullness by weighing or hefting for self-expelling type extinguishers, cartridge-operated extinguishers, and pump tanks every month within the last year.

These deficient practices were confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview, the facility did not maintain corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.6.3.5. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 6/14/2018 at 2:15 PM, observation revealed in the lower level dietary office that the corridor door was held open with a chair.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and staff interview, the facility did not maintain corridor doors in accordance with NFPA 101 (2012 edition), 19.3.6.3.5. Doors shall be provided with a means for keeping the door closed. These deficiencies had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

1. On 6/19/2018 at 11:01 am, observation revealed the inactive leaf on the upper level room number 246A double doors was not automatically positive latching inside the emergency department. If the inactive leaf was not manually latched, both doors would not positively latch and stay closed.

2. On 6/19/2018 at 11:05 am, observation revealed the inactive leaf on the upper level room number 248 double doors was not automatically positive latching inside the emergency department. If the inactive leaf was not manually latched, both doors would not positively latch and stay closed.

3. On 6/19/2018 at 11:08 am, observation revealed the inactive leaf on the upper level room number 252 double doors was not automatically positive latching inside the emergency department. If the inactive leaf was not manually latched, both doors would not positively latch and stay closed.

These deficient practices were confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on observation and interview, the facility failed to provide smoke barrier doors with rabbets, bevels, or astragals in accordance with NFPA 101 (2012 edition), 18.3.7.8(4) and 8.5.4. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 6/14/18 at 1:45 PM, observation of the lower level pair of cross-corridor smoke barrier doors between the smoke compartments revealed a gap greater than 1/8 of an inch at their meeting edges when closed. The doors were observed with no rabbets, bevels, or astragals at their meeting edges.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.

Based on record review and interview, the facility failed to conduct fire drills at varied times in accordance with the requirements of NFPA 101 (2012 edition), Section 19.7.1.4, 19.7.1.5, 19.7.1.6 and 19.7.1.7. This deficiency had the potential to affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 6/14/2018 at 12:55 PM, review of the facility fire drill documents for the last 12 months revealed that fire drills on the first shift were not conducted at varied times. Three of four 1st shift fire drills were conducted between 11:16 am and 11:24 am.

This deficient practice was confirmed by Staff A (Maintenance Director) at the time of discovery.