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Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2.

Findings include:

1. During an observation on 8/25/21 at 10:24 a.m. the Physical Therapy Exam room door was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room has the capacity to hold three or more people.

2. During an observation on 8/25/21 at 10:24 a.m. the kitchen dry storage door was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The kitchen dry storage room has the capacity to hold three or more people.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 08/25/21 at 9:55 a.m., the door leading to Radiology was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

2. During an observation on 08/25/21 at 10:39 a.m., the clean storage door was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings Include:

1. During an observation on 8/25/21 at 10:36 a.m., the activities storage room was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

2. During an observation on 8/25/21 at 10:47 a.m., the wheelchair storage room was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

3. During an observation on 8/25/21 at 10:48 a.m., the housekeeping storage room was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

Based on observation, the facility failed to:
a) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1; and
b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.

Findings include:

1. During an observation on 8/25/21 at 9:58 a.m., the emergency room storage closet was inspected. There was PPE stacked on top of a shelf within 18 inches of a sprinkler head.

2. During an observation on 08/25/21 at 10:49 a.m., the sprinkler pipe in the north penthouse was inspected. A blue cable was observed, attached to the sprinkler pipe within the room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 08/25/21 at 10:13 a.m., the purchasing room was inspected. The portable extinguisher in the room was found to have a large cart being stored in front of it.

Based on record review, the facility failed to maintain the receptacles in patient areas. The deficient practice affected the entire facility.

Findings include:

Record review on 8/25/2021 revealed non-hospital grade receptacles located in resident rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).