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Based on observation and staff interview, the facility failed to maintain doors in occupancy separation in accordance with NFPA 101, 2012 edition, 19.1.3.4.1, 8.3.4, 8.3.3.1, 8.3.3.3. This deficiency had a potential to affect all patients receiving care in ER, as well as an undetermined number of staff and visitors.

Findings Include:

On 6/27/2022 at 1:30 PM, observation revealed that the door from the hospital to the 2 hour connector to the MOB, did not latch when closed. There was excess airflow from the MOB to the hospital that kept the door from closing.

The above deficiency was confirmed at the time of discovery by an interview with Staff Y.

Based on observation and staff interview, the facility did not maintain the proper fire-rating of building structure based on building height in accordance with NFPA 101, 2012 edition, Section 19.1.6.4. This deficiency had a potential to affect undetermined number of staff and visitors in the facility.

Findings include:

On 06/28/2022 at 11 AM, observation revealed the lower corridor wall in the Old PT/OT area in Lower Level, is made of wood, similar to a desk. Wood walls are not permitted in a type II non-combustible construction type.

The above deficiency was confirmed by Staff Z at the time of discovery.

Based on observation, record review and interview, the facility failed to provide (i) exit signs in accordance with NFPA 101, 2012 edition, 39.2.10, 7.10.1.5.1; (ii) exit stair enclosure in accordance with NFPA 101 Life Safety Code, 2012 edition, 21.3.1, 39.3.1.1, 8.6.5, 7.1.3.2.1(3)(b); and (iii) a means of egress in accordance with the requirements of NFPA 101, 2012 edition, Sections 21.2.2.2, 39.2.2.2.5 and 7.2.1.6.1.

Findings include:

1. On 06/27/22 between 2:40 PM and 4 PM, observation revealed that access to exit was not readily apparent due to lack of exit/directional signs in exit access corridor adjacent to Rooms 3356 and 3389 in the 3rd Floor occupational therapy (OT) to direct occupants to exits.

2. On 06/27/22 between 2:40 PM and 4 PM, observation revealed that the exit enclosure, Stair D, adjacent to waiting room was open to 1st Floor at the exit discharge level and not fully enclosed with a minimum of 1-hour fire-resistance rated construction. The stair had an exit sign and was a required means of egress from 3rd Floor. Review of building construction plans between 2:40 PM and 4 PM with Staff Y, however, showed that the exit enclosure, Stair D, was fully enclosed with fire-rated walls in all levels including at the 1st Floor level where the stair exit doors discharged into the waiting/reception and lobby near the main entrance.

3. On 06/27/22 at 3:06 PM, observation revealed the exit door from the PT waiting area into the Rehab area, had a delayed egress on the door. It did not have a sign stating "PUSH UNTIL ALARM SOUNDS, DOOR CAN BE OPENED IN 15 SECONDS".

The above findings were confirmed by an interview with Staff Y at the time of discovery.

Based on observation and staff interview, the facility did not ensure that egress corridors are continuously maintained free of materials or devices that obstruct egress in accordance with NFPA 101 (2012 edition) sections 19.2.1, 7.1.10.1. The deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 06/27/2022 at 10:25 AM, observation revealed that in the exit passageway exiting to the loading dock area, had an EVS cart in the exit passageway blocking it. There was no one around, it was unattended.

The deficient practice was confirmed and mentioned to Staff Y later in the day.

2. On 06/28/2022 at 2:40 PM, observation revealed that the corridor between rooms 205-206 in the surgery area was obstructed by weight station, chair not secured to the floor or wall, and trash (soiled linen) bin.

The deficient practice was confirmed at the time of discovery by a concurrent interview with Staff Z.

Based on observation and interview, the facility did not properly maintain fire-rated door in accordance with NFPA 101, 2012 edition, Sections 19.2.2.2.7, 8.3.3.3. This deficiency had a potential to affect all patients receiving care in the emergency department, and an undetermined number of staff and visitors in the facility.

Findings include:

On 06/27/2022 at 3:35 PM, observation revealed that the 90 minute fire-rated door to the decontamination room for the ED did not latch.

The above deficiency was confirmed by Staff Z at the time of discovery.

Based on observation and staff interview, the facility did not ensure that stairways and exit passageway are in accordance with NFPA 101, 2012 edition, 19.2.2.3, 7.2.1.8. This deficiency had a potential to affect all patients receiving care in surgery area and an undetermined number of staff in the facility.

Findings Include:

On 06/28/2022 at 3:05 PM, observation revealed that the exit door to the stairway by the nurse station of the surgery area on the 2nd Floor did not close automatically when door was fully open. The door 'hung up' on the floor.

The above deficiency was confirmed by an interview with Staff Z at the time of discovery.

Based on observation and staff interview, the facility did not ensure that exit passageway was in accordance with 19.2.2.7, 7.2.6.2, 7.1.3.2.1(9), 7.1.3.2.1(8), 8.3.3. This deficiency had a potential to affect an undetermined number of patients, staff and visitors in the facility.

Findings include:

1. On 6/27/2022 at 11:00 AM, observation revealed that the exit passageway from Stairwell (exits to loading area) has the biohazard room, an unoccupied space, opening up onto it.

2. On 6/27/2022 at 11:05 AM, observation revealed that the door from the corridor (Mechanical room corridor) to the exit passageway, did not close and latch. The double doors did not have a door coordinator and hung up. The button on the "inactive" leaf hung up in the open position and did not latch.

The above deficiency was confirmed at the time of discovery by a concurrent interview with Staff Y.

Based on observation and interview, the facility failed to provide illumination of exit discharge from 1 of 7 exits in accordance with NFPA 101 (2012 edition) 19.2.8, 7.8. This deficiency had the potential to affect an undetermined number of patients, staff and visitors in the facility.

Findings include

On 06/28/22 between 1:30 PM and 1:45 PM, observation revealed that the exit discharge from stair exit adjacent to the Administration area on the 1st Floor was not illuminated with normal power lighting.

The above finding was confirmed by an interview with Staff Y at the time of discovery.

Based on observation and interview, the facility failed to provide emergency lighting in exit discharges from 2 of 7 exits in accordance with NFPA 101 (2012 edition) 19.2.9.1, 7.9. This deficiency had the potential to affect patients who receive care on 1st and 2nd Floors, and an undetermined number of staff and visitors.

Findings include

1. On 06/28/22 at 1:12 PM, observation revealed that the exit discharge from stair exit adjacent to Cardiac Rehab on the 1st Floor did not have emergency lighting where the discharge makes a second 90 degree change in direction.

2. On 06/28/22 at 1:30 PM, observation revealed that the exit discharge from stair exit adjacent to the Administration area on the 1st Floor did not have emergency lighting.

The above findings were confirmed by an interview with Staff Y at the time of discovery.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.2.10.1, 7.10. This deficiency could affect ER patients and an undetermined number of staff and visitors.

1. On 06/27/2022 at 3:40 PM, observation revealed that the door from the Ambulance garage to the exit vestibule did not have an exit sign.

The above finding was confirmed at the time of discovery by a concurrent interview with Staff Z.

12316

Based on observation and interview, the facility failed to maintain (i) all framing of interior walls and partitions of non-combustible construction in accordance with the requirements of NFPA 101 2012 edition, Sections 18.3.2.1, 8.7.1.1; and (ii) corridor doors of one hazardous room in accordance with NFPA 101, 19.3.2.1, 8.4.3. This deficient practice could affect an undetermined number of patients, as well as staff and visitors in the building.

Findings include:

1. On 06/28/2022 at 11:16 am, observation revealed that the receiving staging area in the old PT/OT Rehab is a room approximately about 45' X 90' that is full of combustible storage. The walls are not fire rated and there are no fire rated doors. This area is a new storage area since the PT/OT left approximately 3-5 years ago.

2. On 06/28/22 at 2:02 pm, observation revealed that the corridor door protecting opening in walls enclosing the Gift Shop Storage Room M105 on 1st Floor did not latch.

The above deficiency was confirmed by an interview with Staff Y and Z at the time of discovery.

Based on observation and interview, the facility did not properly install the building sprinkler system in accordance with NFPA 101 19.3.5.3, 9.7.1.1, NFPA 13, 2010 ed., 8.6.6.1. This deficient practice could affect undetermined number of patients, as well as staff and visitors.

Findings include

1. On 06/28/22 at 11:07 am, observation revealed that clearance between deflector of sprinkler head and top of Marketing Storage in old PT/OT and Gym in Lower Level, currently used as a storage, was less than 18 inches.

2. On 06/28/22 at 11:15 am, observation revealed that clearance between deflector of sprinkler head and top of boxes on wood pallets in old PT/OT and Gym in Lower Level, currently used as a storage, was less than 18 inches.

3. On 06/28/22 at 11:25 am, observation revealed that clearance between deflector of sprinkler head and top of storage in old PT/OT and Gym "Bowling Alley" room in Lower Level, currently used as a storage, was less than 18 inches.

4. On 06/28/22 at 11:32 am, observation in the Central Supply, revealed storage rack did not have the 18" vertical clearance from the sprinkler head, which obstructed the sprinkler.

The above deficiency was confirmed by Staff Y and Z at the time of discovery.






12316

Based on observation and interview, the facility failed to store soiled linen and trash receptacles in accordance with the requirements of NFPA 101 (2012 edition), sections 21.7.5.7.1. In addition, based on record review and interview the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 21.7.1, 21.7.2. This deficient practice could affect all patients who receive care, and undetermined number of staff and visitors.

Findings include:

1. On 06/27/2022 at 2:20 PM, observation in the nurse passage of the Infusion area of the Medical Office Building, revealed two 32-gallon trash containers next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.

2. On 06/27/2022 at 2:25 PM, in the Infusion department, staff HH was asked about what s/he would do about the oxygen supply in the patient rooms in case there was a fire. S/he did not know (remember) to check to see if other patients need oxygen before shutting off the oxygen supply valve.

The above findings were confirmed at the time of discovery by a concurrent interview with Staff Y.

Based on record review and interview the facility failed to conduct fire drills in accordance with, the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.2.1.2. This deficient practice could affect all inpatients, outpatients, staff and visitors.

Findings include:

On 06/27/2022 at 4:00 PM, in the ED department, Staff II was asked about what s/he would do about smoking coming from an ER exam room. S/he knew RACE, but did not know where the pull station was for the fire alarm.

This finding was confirmed at the time of discovery by an interview with Staff II and Staff Z observing.

Based on observation and staff interview, the facility failed to provide wall decoration on the walls in the corridor of the surgery area in accordance with NFPA 101 - 2012 edition, section 19.7.5.6.. This deficient practice had a potential of fire hazard or serious burns.

Findings Include:

1. On 06/28/2022 at 3:00 PM, observation revealed that in corridor next to the nurse station in the surgery area, 41 coats were hanging on hooks. They were not fire treated. It was similar to decorations hanging on a wall.

These deficient practices were confirmed by Staff Z at the time of discovery.

Based on observation and interview, the facility failed to store soiled linen and trash receptacles in accordance with the requirements of NFPA 101 (2012 edition), sections 19.7.5.7.1. This deficient practice could affect all patients, staff and visitors.

Findings include:

1. On 06/28/2022 at 8:42 AM, observation in the chemo sterile room, revealed four trash bins containers next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.

2. On 06/28/2022 at 2:50 PM, observation in the corridor of the surgery area between surgery nurse station and room 201, revealed two 32-gallon trash containers next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff Y and Staff Z

Based on observation and staff interview, the facility failed to provide proper space heater in an office in accordance with NFPA 101, 2012 edition, 19.7.8. This deficient practice had a potential of fire hazard or serious burns.

Findings include:

On 06/28/2022 at 1 PM, observation revealed that in Room 237, an office on the patient floor, had a space heater with electrical heating element that were wire coils. The heating element is required to be below 212 F and the wires exceed that temperature when in use. This deficiency was confirmed by Staff Z at the time of discovery.

Based on observation and interview, the facility failed to provide manual emergency stop switch in a remote accessible location in accordance with NFPA 101, 2012 edition, 21.7.5.1.1, 39.5.1, 9.1.2 and NFPA 110, 2010 edition, 5.6.5.6, NFPA 110 6.6.3.1.2.

Findings include:

1. On 06/28/2022 at 3:26 PM, observation at the interior emergency generator revealed that there was not a remote emergency stop switch outside of the generator room. There is an emergency stop switch on the generator panel, which is not considered remote.

2. On 06/28/2022 between 2 and 4 pm, review of emergency generator maintenance records revealed that the transfer time of Automatic Transfer Switch of essential power system of the medical office building (MOB) that supplied emergency power to loads in the life safety branch circuits was more than 10 seconds; the transfer time varied from 73 seconds to 190 seconds.

The above findings were confirmed by interview with Staff Y and Z at the time of discovery.

The code provision requiring a remote manual stop station was also found in the 1999 edition of NFPA 110 s. 3-5.5.6.

Based on observation and interview, the facility did not maintain the proper distance from a building and the bulk oxygen tank in accordance with NFPA 99, 2012 edition, 5.1.3.5.12.2 and NFPA 55, Table 9.3.2, Minimum Separation Distance Between Bulk Liquid Oxygen Systems and Exposure Hazards.

Findings include:

On 06/27/2022 at 11:14 AM, observation revealed that the MRI truck (parked vehicle) was within 10 feet of the bulk liquid oxygen tank (observed 6/28 at 2 PM); plants within 5 feet of the oxygen tank; trash bin (9' X 6 ' X 40') full of quick burning combustible trash within 5 feet; within 50 feet of inpatients rooms and patient in the MRI, and there was mold and weeds growing below the oxygen tank.

This deficient practice was confirmed by Staff Z at the time of discovery.

Based on observation and interview, the facility did not maintain the proper labeling of the medical air and vacuum pipes and did not properly label zone shut-off valves in accordance with NFPA 99, 2012 edition, 5.11.1 and 5.1.11.2. This had a potential to affect all patients in the facility.

Findings include:

1. On 06/28/2022 at 8:14 AM, observation revealed that the pipes to/from the Medical air compressor and the Vacuum pump were not properly labeled. The names and direction of flow arrows were missing.

2. On 06/28/2022 at 12:50 PM, observation revealed that the zone valve shut-off box did not identify that it shut off patient room 230.

The deficient practice was confirmed at the time of discovery by a concurrent interview with Staff Z.

Based on observation and staff interview, the facility failed to properly maintain electrical receptacles in accordance with NFPA 101 (2012 edition), Sections 19.5.11, 9.1.2, NFPA 70 (2011 edition) Section 517.19(A). This deficiency could affect an all patients who receive care in 3 of 4 surgery rooms.

Findings include:

On 06/28/2022 between 3:15 PM to 3:45 PM, observation in the Operation Rooms 1, 2 and 3 revealed that electrical wall receptacles in critical branch circuits were marked red but the receptacles were not identified with the panel board and circuit breaker number the power was supplied by.

The above finding was confirmed by interview with Staff Z and N at the time of discovery.

The above referenced code provision was also included in the 1999 edition of NFPA 70.

Based on record review and interview, the facility failed to perform maintenance of essential electrical system equipment in accordance with NFPA 101, 2012 edition, 9.1.3.1, NFPA 99, 2012 edition, 6.4.4.1.1, NFPA 110, 2010 edition, 8.3.5. The deficiency had the potential to affect all patients in the facility.

Findings include

On 06/29/22 between 9 am and 11:15 am, review of maintenance records of essential power supply system (EPSS) revealed that automatic transfer switches (ATS) were not inspected and maintained when the emergency generator was last serviced by Interstate, and that there was no evidence available at the time of survey of ATS maintenance that had been performed earlier.

The above finding was confirmed with Staff Y and Z at the time of record review, and Staff A and Staff C at the time of exit interview on 06/29/22.

12316

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of clear working space in front of electrical equipment and switches in accordance with NFPA 101, 2012 edition, 19.5.1, 9.1.2, NFPA 70 Sections 110.34(A), 110.26, (312.11), and 408.4(A). The deficiency had the potential to affect all patients and undetermined number of staff in the facility.

Findings include

1. On 06/27/2022 at 3:50 PM, observation in the Biohazard room of the ER revealed that access to the electrical disconnect was less than the minimum required 3'-0" clearance. A biohazard bin was stored in front of the electrical panel.

2. On 06/28/2022 at 11:33 am observation in the central supply room revealed that the labeling of the electrical panel did not match the numbering on the breakers.

3. On 06/28/22 at 11:44 am, observation revealed that the working space provided in front of an electrical transformer in the old PT/OT and Rehab area in Lower Level was less than 36 inches. The clear space in front of transformer and back of steel storage cabinets was measured to be 22 inches.

4. On 06/28/22 at 11:50 am, observation revealed that the working space provided in front of an electrical transformer was less than 36 inches due to seven boxes of storage on wood pallets.

5. On 06/28/22 at 11:55 am, observation revealed that the working space provided in front of an electrical disconnect switch on wall of the Laundry Room was less than 36 inches due to a clean linen cart stored in front of the switch.

The above findings were confirmed by interview with Staff Y and Staff Z at the time of discovery.