HospitalInspections.org

Based on observation during the survey walk-thru, means of egress are not maintained to provide protected and unimpeded paths to exits. This deficient practice could affect patients, staff and visitors if a failure to provide required paths compromise access and level of safety for occupants.

The finding is:

On 08/22/2019 at 1:10pm while in the company of the DM it was observed that the 1st floor Atrium space is used for dining. One table and four chairs are located less than three feet from a designated exterior discharge door. The stationing of the tables and chairs (one set in front of each exterior discharge door) in the required path of egress reduces the available width of egress and does not comply with the requirements of 19.2.3.4(1) and 19.2.3.5.

Based on observation, not all designated fire barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors on the building because fire could pass between adjacent fire compartments if fire barriers are not properly constructed.

The finding is:

On 08/22/19 at 1:25pm, while in the company of the DM, a designated 2 hour fire barrier is incomplete due to the pair of cross corridor fire rated doors which do not close to a latched position to comply with 8.3.5.7. Location observed: 2nd story fire barrier doors adjacent to Patient room #201.

Based on document review and staff interview, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

The finding is:

On 08/23/2019 at 9:45am, while in the company of the DM during document review battery powered emergency lighting annual testing for the 1.5 hour duration was not conducted and recorded to comply with 7.9.3.1.1 (3).

Based on observation the facility failed to install complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On 08/22/19 at 2:35pm while in the company of the DM the Main Lobby atrium space was observed to contain two skylights greater than three feet deep which are without fire sprinkler protection. This condition does not comply with NFPA 13, 2010, 8.6.7.2

Based on observation, the facility failed to install and maintain automatic sprinkler protection in accordance with the code requirements. This deficient practice could impair activation of the sprinkler system and delay an emergency response.

Finding includes:

A. On 08/23/2019 at 9:45am while in the company of the DM, documentation for the fire pump inspection dated 01/24/19 and 04/12/19 read that " packing service may soon be required" the inspection dated 08/13/2019 read "clean packing and adjust packings". During an interview this work has not yet been performed by the vendor. This condition does not comply with NFPA 25 2011, 8.3.2 and table 8.6.1.

B. On 08/22/2019 at 3:10pm while in the company of the DM, the alarm panel in the fire pump room indicates a trouble signal and reads "no disc". It is unknown which information the disc is used for recording, however, the recording of the pressure in the fire pump controller pressure-sensing line at the input (city pressure) and the testing of city pressure is required in order to comply with NFPA 20 2010, 10.5.2.1.7.2 and 10.5.2.1.7.3.

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

The finding is:

On 08/23/2019 at 10:00am during document review in the company of the DM, Facility fire drill documentation for the past 12 months did not indicate the following:
1. Which fire alarm device is activated.
2. Transmission of a signal to the monitoring service or fire department.

Based on document review and staff interviews, the facility failed to provide compliant smoke management systems. This deficient practice could result in the uncontrolled spread of products of combustion during a fire event, which may affect patients, staff and visitors.

Findings include:

On 08/23/2019 at 10:15am while in the company of the DM, documentation was not be provided to demonstrate semi-annual testing of the facilities atrium smoke control systems to comply with NFPA 92, 2012, 8.6.

Based upon observation, the Essential Electrical System (EES) is not maintained in accordance with a Type 1 EES. Failure to maintain the EES as a Type 1 system can result in loss of electrical service for critical patient care needs.

The finding is:

On 08/22/2019 at 2:45pm while in the company of the DM Critical Care bed locations within Recovery stations considered as Stage I, (two Stage I bays required) do not comply with NFPA 99-2012, 6.3.2.2.6.2(B) for a minimum 14 receptacles.

Based upon observation, medical gas storage is not in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to properly store medical gases were to permit stored gases to contribute to the accelarated spread or intensity of a fire at the location.

Findings include:

A. On 08/22/2019 at 10:50am while in the company of the DM it was observed that cylinder racks for E-size tanks were located in the 2nd floor clean holding room and were not separated from combustible storage by a minimum distance of 5 feet to comply with NFPA 99-2012, 11.3.2.3.

B. On 08/22/2019 at 3:15pm while in the company of the DM, empty, partial and full cylinders are not stored in a separated manner within the same enclosure to comply with NFPA 99, 2012 11.6.5.2. There is no signage for cylinders which makes it clear which group is empty or full since there is no separation. This condition does not comply with NFPA 99, 2012, 11.6.5.3. Location observed: Medgas Manifold room.