HospitalInspections.org

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Based on observation and interview the facility failed to ensure an exit discharge door was free from signage that would delay, prevent, or deter the use of the door in accordance with NFAP 101: 7.1.10.1. This failed practice place occupants using 1 of 3 exit discharges in 1 of 2 smoke compartments at risk for delay in egress. Findings:

Observation on 9/23/21 revealed an exit discharge door located outside patient room B105 with signage that read "Push Until Alarm Sounds Door Can Be Opened in 15 Seconds". When tested the door did not have any form of delayed egress.

This finding was acknowledged by the Facilities Director at the time of its discovery and stated the door should have the sign removed.

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Based on observation and interview the facility failed to ensure an exit egress was labeled with an exit sign in accordance with NFPA 101: 7.10 as referenced by NFPA 101: 18.2.10.1. This failed practice placed occupants in 1 out 2 smoke compartments at risk for delay in egress. Findings:

Observation on 9/23/21 revealed the T-junction of corridor G181 and corridor G182. Further observation revealed no visible exit sign marking the means of egress from either corridor.

This finding was acknowledged by the Facilities Director at the time of its discovery.
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Based on observation and interview the facility failed to ensure shut off valves were labeled in accordance with NFPA 99: 5.1.11.2 as referenced by NFPA 101: 18.3.2.4. This failed practice placed all occupants in 1 out 1 smoke compartment with shut off valves at risk for exposure to a smoke and/or fire environment. Findings:

Random observation on 9/23/21 revealed the shut off valves for acute care rooms 1, 2, 3, and 4; trauma room, "FLEX" room, "FLEXSAFE" room, procedure room, Mammography, Ultrasound, CT room, and X-Ray room. There was a total of 6 shut off valve boxes. Further observation revealed each shut off valve box was labeled with the corresponding room on the removable plastic cover. As a result, when the cover was removed, the actual shut off valves were unlabeled.

These findings were acknowledged by the Facilities Director at the time of their discovery.

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Based on observation and interview the facility failed to ensure electrical supply cords, power strips and extension cords were used and/or maintained in accordance with NFPA 99: Chapter 10 and NFPA 70. This failed practice placed occupants in 2 of 2 smoke compartments at risk for exposure to a fire and/or smoke environment secondary to electrical fire potential. Findings:

Observation of Lab Supply Room (D127) on 9/23/21 at 9:29 am revealed a power strip plugged into another power strip that was powered by an extension cord. Specifically, the extension cord supplied power to a power strip that supplied power to a microwave and an additional power strip. The additional power strip was supplying power to a refrigerator.

This finding was acknowledged by the Facilities Director at the time of its discovery and stated the observed use of the extension cord and two power strips were not acceptable by facility safety standards.

Observation of the nurses' computer station on 9/23/21 at 9:37 am revealed two suspended electrical power supply cords powering computer equipment. Specifically, the AC/DC converter box was suspended in mid-air causing undue stress to the wiring.

Observation of the laundry area on 9/23/21 at 10:11 am revealed a suspended electrical power supply cord powering computer equipment. Specifically, the AC/DC converter box was suspended in mid-air causing undue stress to the wiring.

These findings were acknowledged by the Facilities Director at the time of their discovery.
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