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Tag No.: K0293
Based on observation and interview, the facility failed to provide exit signs in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.2.10.1 and 7.10.1.2.1. This had the potential to affect 6 patients on the floor that may use this emergency path of egress. The facility census was 45.
Findings include:
On 11/19/19 at 2:53 P.M., during a tour of the facility with the director of facilities and the director of environmental and safety, the safety and health consultant observed an exit sign was not posted over the cross-corridor security doors in the exit corridor just south of resident room 317. Furthermore, the exit sign at the south end of this exit corridor was not visible when the security doors were in their normal closed position. Interview with the Director of Facilities verified this finding at the time of discovery.
Tag No.: K0321
Based on observation and interview, the facility failed to ensure protection from hazardous areas in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3.2. This had the potential to affect 9 residents observed in a smoke compartment that may use the emergency paths of egress through the corridors communicating with these hazardous areas. The facility census was 45.
Findings include:
On 11/21/19, during a tour of the facility with the Director of Facilities and the Director of Environmental and Safety, the following was observed:
1. At 9:44 A.M., a one-gallon container of 95% Ethanol and a small bottle of 70% Isopropyl Alcohol were observed in the basement laboratory prep. room, which measured greater than 50 square feet in size; yet the door separating this room from the remainder of the suite was not provided with a self-closing device; and
2. At 10:39 A.M., the inactive leaf of the dual-leaf door system separating the basement level maintenance shop from the exit corridor was not provided with positive latching hardware. Specifically, the inactive leaf was provided with a manual flush-bolt only.
Interview with the Director of Facilities verified the above findings at the time of discovery.
Tag No.: K0347
Based on observation and interview, the facility failed to ensure all areas open to the corridor were equipped with smoke detectors in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3 and 9.6.1.3, and Edition 2010 of NFPA 72, National Fire Alarm and Signaling Code, Section 17.7.3. This had the potential to affect 7 patients observed in the smoke compartment. The facility census was 45.
Findings include:
On 11/19/19 at 2:07 P.M., during a tour of the facility with the Director of Facilities and the Director of Environmental and Safety, observation revealed the ER triage room was open to the exit corridor by way of a ten inch by thirty-six inch sliding glass window opening; yet this room was not provided with a smoke detector. Review of floor plans provided by the facility revealed this area had previously been separated from the exit corridor by way of a swinging door. Upon request, the facility was unable to provide evidence to show the configuration of smoke detectors in the ER were part of an approved installation. Interview with the Director of Facilities verified this finding at the time of discovery.
Tag No.: K0351
Based on observation and interview, the facility failed to provide automatic sprinkler protection throughout the hospital in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3.5.1 and 9.7.1.1(1). This had the potential to affect all 45 patients in the facility by way of disrupting essential building services and impeding staff from responding to a disaster or emergency.
Findings include:
On 11/21/19 at 11:01 A.M., during a tour of the facility with the Director of Facilities and the Director of Environmental and Safety, the print room was observed, located within the electrical room containing the emergency power supply system transfer switches, was enclosed by way of gypsum board wall construction and suspended ceiling tiles under a wooden deck; yet this room was not sprinklered. Interview with the Director of Facilities verified the above findings at the time of discovery.
Tag No.: K0363
Based on observation and interview, the facility failed to ensure doors were provided with positive latching hardware in accordance with Edition 2012 of NFPA 101, Life Safety Code, Section 19.3.6.3, and 42 CFR §482.41(b)(ii). This had the potential to affect all 45 patients in the facility.
Findings include:
During a tour of the facility with the Director of Facilities and the Director of Environmental and Safety, the following were observed:
1. On 11/19/19 at 1:02 P.M., the inactive leaf of the dual-leaf door system separating the 1st floor west valve closet from the exit corridor was not provided with positive latching hardware. Specifically, the inactive leaf was provided with a manual flush-bolt only;
2. On 11/19/19 at 4:12 P.M., the inactive leaves of the dual-leaf door systems separating the six offices located off the west side of the exit corridor in the southwest corner of the 3rd floor were not provided with positive latching hardware. Specifically, the inactive leaves were provided with manual flush-bolts only;
3. On 11/20/19 at 4:48 P.M., the inactive leaf of the dual-leaf door system separating the 2nd floor inpatient endoscopy room from the exit corridor was not provided with positive latching hardware. Specifically, the inactive leaf was provided with a manual flush-bolt only;
4. On 11/21/19 at 8:10 A.M., the inactive leaves of the dual-leaf door systems separating the 1st floor nuclear medicine rooms 1 and 2 from the exit corridor was not provided with positive latching hardware. Specifically, the inactive leaves were provided with manual flush-bolts only;
5. On 11/21/19 at 9:54 A.M., the door separating west side of the basement laboratory from the exit corridor near the main patient elevators was not provided with a means suitable for keeping the door closed. Specifically, the strike plate latch was not held by the electronic locking mechanism and the door pushed open without the need to use the door handle to unlatch the thrust bolt from the strike plate. According to interview with the director of environmental and safety, the electronic locking mechanism for this door was deactivated from 7:00 A.M. to 4:00 P.M., Monday through Friday;
6. On 11/21/19 at 4:48 P.M., the inactive leaf of the dual-leaf door system separating the basement level print shop from the exit corridor was not provided with positive latching hardware. Specifically, the inactive leaf was provided with a manual flush-bolt only; and
7. On 11/21/19 at 10:48 A.M., the inactive leaf of the dual-leaf door system separating the south side of the basement level pharmacy from the exit corridor was not provided with positive latching hardware. Specifically, the inactive leaf was provided with a manual flush-bolt only.
Interview with the Director of Facilities verified the above findings at the time of discovery.
Tag No.: K0781
Based on observation and interview, the facility failed to prohibit the use of portable space heaters in smoke compartment containing patient sleeping rooms in accordance with Edition 2012 of NFPA 101, Life Safety Code, Section 19.7.8. This had the potential to affect 21 patients in the smoke compartment. The facility census was 45.
Findings include:
On 11/21/19 at 8:37 A.M., during a tour of the facility with the Director of Facilities and the Director of Environmental and Safety, a 1500 Watt portable space heater was observed, which was plugged into an electrical outlet in the 2nd floor clinical nurse leader office across the exit corridor from and in the same smoke compartment as patient room PCU 219. Interview with the Director of Facilities verified the above findings at the time of discovery.