HospitalInspections.org

Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations.
Findings:

During the facility tour, between the hours of 8:30am and 4:00pm, it was observed that one of the exit doors would not open. NFPA 101 7.2.1.4.5.1(2) states exit doors should not require more than 50lbs applied to the latch. Also NFPA 101 7.1.9 states any any device or alarm installed to restrict the improper use of a means of egress shall be designed
and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress

Interview with Administrator revealed the facility was not aware that the exit door would not open.

Based on visual observation and record review the facility failed to assure that annual inspections were conducted on all fire doors in fire rated assemblies.

Findings:

During facility tour between the hours of 8:30am and 4:00pm, it was observed that no fire door annual inspections were completed. NFPA 80 7.2.1.5 requires all fire doors to be inspected by a person with knowledge of the fire doors and have inspection completed annually.

Interview with Administrator revealed he was unaware of the annual required for fire doors.

Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building. The exit discharge was deficient for 1 of 3 exits.

Findings:

During the facility tour, between the hours of 8:30am and 4:00pm it was observed that one of the exits did not have a level walking surface free of obstructions and a all weather travel surface to the public way.

Interview with Administrator revealed the facility was not aware that the exit discharge did not continue to the public way.

Based on visual observation the facility failed to provide sensitivity testing on the building smoke detectors that are connected to the fire alarm system. The detectors offer a means of activating the fire alarm system to provide emergency notification to the occupants of the building. This deficiency has the potential to affect of residents.

Findings:

During the facility tour, between the hours of 8:30 am and 4:00pm, it was observed, that the new emergency room addition has a 2-hour fire wall and is only protected by smoke detection on one side, which is the existing side. Smoke detection is required within 15 feet per NFPA 72 17.7.5.6.2.

Interview with Administrator revealed the facility was not aware the smoke detection was missing on the new area in the emergency room. During the exit interview this was also acknowledged by the Administrator

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 140 of 140 residents.


Findings:

During the facility tour, between the hours of 8:30am and 4:00pm, it was observed that several penetrations in the firewall were found on the first and second floors.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 140 of 140 residents.
3 of 4 quarters in 2018 were deficient.

Findings:

During the record review, between the hours of 8:30am and 4:00pm, it was observed that during records review of fire drills only2nd quarter drills could be located. No 1st, 3rd or 4th drills were documented.

Interview with Administrator revealed the facility was not aware fire drills were not being documentated and verified by the Administrator during the exit interview.

Based on visual observation and record review the facility failed to provide medical gas documentation with all areas passing inspection. Record review shows several areas with leaks, low pressure and med gas that is piped in backwards.

Findings:

During the facility tour between the hours of 8:30am and 4:00pm, it was observed, that upon review of med gas documentation several areas failed inspection. Deficiencies found ranged from low pressure, leaks and med gas that was piped backwards.

Interview with Administrator revealed he was unaware of the deficiencies found in the med gas reports.