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Based on observation and staff interview, the facility failed to maintain means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain means of egress could result in reduced ability to evacuate the facility in an emergency which could result in injury or death. The deficiency affected the basement floor, in a non-patient care area, and could impact all staff and visitors in the area.

The findings were:

Observation on 11/07/2022 at 10:21 AM revealed a corridor located adjacent to the sterile processing suite and central laundry area. Observation of the corridor revealed large quantities of combustible storage being kept in the corridor, as well as wheeled hampers used for collecting and transporting laundry. The corridor was eight (8) feet in width and in an area not intended for the use of patients. The storage was kept on one side of the corridor and projected approximately two (2) feet into the corridor width. The wheeled hampers were being kept on the opposite side of the corridor, and projected approximately three (3) feet into the corridor width. Means of egress shall be continuously maintained free of all obstructions of impediments to full instant use in case of fire or other emergency.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.2.1, 7.1.10.1

Based on observation and staff interview, the facility failed to maintain egress doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain egress doors could result in reduced ability to evacuate the facility in an emergency which could result in injury or death. The deficiencies affected three (3) of numerous egress doors throughout the facility and could impact all patients, staff, and visitors in those areas.

The findings were:

1) Observation on 11/07/2022 at 11:03 AM revealed double-doors to the materials management room that were equipped with magnetic locks. Observation of the doors revealed that they were normally locked and were equipped with a motion sensor and a manual release button on the egress side as means of unlocking the doors. Testing the motion sensor revealed that it would not unlock the doors, and that the manual release button was required to unlock the doors. Doors located in the means of egress shall be permitted to be locked if provided with a motion sensor and manual release button, and that the locks deactivate on fire alarm activation and power outage.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.2.2.2.4(3), 7.2.1.6.2


2) Observation on 11/07/2022 at 2:21 PM revealed a marked exit door into an exit stairway that was equipped with a magnetic lock. Observation of the door revealed that the door was normally locked and was equipped with a card reader as the only means of egressing through the door. Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by the Life Safety Code. The door was located adjacent to the wound care suite and OR suite, so there was no obvious need for the door-locking arrangement based on the clinic needs of patients requiring specialized security measures, or patient special needs requiring specialized protective measures for their safety.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.2.2.2.4

3) Observation on 11/07/2022 at 2:31 PM revealed a set of cross-corridor doors, that are part of a smoke compartment wall, located adjacent to the account suite and the wound care suite. The cross-corridor doors were marked as exits on both sides of the doors and that the doors are normally locked with magnetic locks. Observation of the doors revealed that the north side of the doors were equipped with a motion sensor as a means of unlocking, and on the south side of the doors they were equipped with a card reader as a means of unlocking. Doors located in the means of egress shall be permitted to be locked if provided with a motion sensor and manual release button, and that the locks deactivate on fire alarm activation and power outage. There was no obvious need for the door-locking arrangement based on the clinic needs of patients requiring specialized security measures or patient special needs requiring specialized protective measures for their safety.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were unaware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.2.2.2.4(3), 7.2.1.6.2

Based on observation and staff interview, the facility failed to protect vertical openings in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly protect vertical openings could result in spread of smoke and fire which could result in injury or death. The deficiencies affected one (1) of one (1) atrium and could impact all patients, staff, and visitors.

The findings were:

1) Observation on 11/08/2022 at 2:20 PM revealed a door to conference room "HooDoo" that is part of the 1-hour fire barrier that protects the atrium connecting the basement floor dining area, 1st floor main lobby, and the 2nd floor waiting area. Observation of the door revealed that is was not labeled as a 45 minute fire-rated door, and was equipped with panic hardware. Atriums shall be protected with 1-hour fire resistant enclosures which requires all openings be protected by 45 minute rated doors with approved fire exit hardware.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.1, 19.3.1.1, 8.6.7, Table 8.3.4.2, 7.2.1.7.2

2) Observation on 11/08/2022 at 2:30 PM revealed a set of cross-corridor doors located in the main dining area on the basement floor opening into the dietary corridor adjacent to the kitchen. Observation of the doors revealed they were part of the 1-hour fire resistant enclosure of the atrium. Observation revealed that the doors were labeled as 45 minute fire-rated doors, but the hardware was labeled as panic hardware. Fire-rated doors shall be equipped with approved fire exit hardware.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.1, 19.3.1.1, 8.6.7, Table 8.3.4.2, 7.2.1.7.2

3) Observation on 11/08/2022 at 2:40 PM revealed a door located in the ED waiting room that opened into a storage room formally used as a bereavement room. Observation of the door revealed it was part of the 1-hour fire resistant enclosure of the atrium. Observation revealed that the door was labeled as a 45 minute rated fire resistant door, but it was equipped with a transfer air opening, so it no longer protected the area from fire and smoke.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.1, 19.3.1.1, 8.6.7, Table 8.3.4.2

Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly protect hazardous areas could result in spread of smoke and fire which could result in injury or death. The deficiency affected the ED suite and could impact all patients, staff, and visitors in the area.

The findings were:

Observation on 11/07/2022 at 2:20 PM revealed a door located in the ED suite that opened into a storage room formally used as a bereavement room. Observation of the room revealed it contained a large amount of combustible storage, and was over 50 sq. ft. in size. It was observed that the door that opens into the ED suite was not equipped with an automatic closer. Storage rooms greater than 50 sq. ft. in size and containing combustible materials shall be separated from other spaces by smoke partitions and the doors shall be self or automatic closing.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.1.2, 19.3.2.1.3

Based on observation and staff interview, the facility failed to protect cooking facilities in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 96, Standard for the Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to properly protect cooking facilities could result in the spread of smoke and fire, which could result in injury or death. The deficiency affected the kitchen and could impact all staff and visitors within the kitchen.

The findings were:

Observation on 11/07/2022 at 12:25 PM revealed multiple gas-fire cook-tops and a deep fryer under a commercial exhaust hood located in the facility's kitchen. Observation of the cook-tops and deep fryer revealed that no means was provided to ensure they were returned to the approved location after being moved. Observation of the ansul extinguishing system spray heads revealed that the cook-tops and deep fryer were not located correctly under the spray heads, and if the ansul system was to activate, it could potentially miss any active fires on the cooking equipment. Cooking appliances requiring fire-extinguishing protection shall be provided with a means of return to the approved location after being moved for cleaning or maintenance purposes.

Interview with the facilities director at the time of the observation acknowledge the deficiency, but indicated they were unaware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.2.5.1, 9.2.3; 2011 NFPA 96 12.1.2.3

Based on document review and staff interview, the facility failed to test and maintain the fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to properly test and maintain the fire alarm system as required may lead to system failure, which could result in injury or death during an emergency. The deficiencies could impact all patients, staff, and visitors within the facility.

The findings were:

Document review on 11/08/2022 starting at 3:20 PM revealed that testing of the notification devices for the fire alarm system had been tested in the last twelve months, however, the test report did not include a list of all notification devices tested with a location description.

Interview with facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2010 NFPA 72 Table 14.4.5(20), 14.6.2.4, Figure 14.6.2.4

Based on document review and staff interview, the facility failed to test and maintain the fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to properly test and maintain the fire alarm system as required may lead to system failure, which could result in injury or death during an emergency. The deficiency could impact all patients, staff, and visitors within the facility.

The findings were:

Document review on 11/08/2022 starting at 3:20 PM revealed that testing of the notification devices for the fire alarm system had been completed in the last twelve months, however, the test report did not include a list of all notification devices tested with a location description.

Interview with facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2010 NFPA 72 Table 14.4.5(20), 14.6.2.4, Figure 14.6.2.4

Based on observation and staff interview, the facility failed to install the fire sprinkler system in accordance with the 2010 NFPA 13, Installation of Sprinkler Systems. Failure to properly install the fire sprinkler system could result in spread of smoke and fire, which could result in injury or death. The deficiency affected the large basement mechanical room and could impact all staff and visitors in the area.

The findings were:

Observation on 11/07/2022 at 10:45 AM revealed a suspended Air Handling Unit (AHU) located in the large basement mechanical room on the Monument side of the facility. Observation of the AHU revealed that it had been installed below a sprinkler head and obstructed the area below it from coverage from the fire sprinkler system. Observation of the space below the AHU revealed racks containing storage of maintenance supplies for equipment in the mechanical room. Fire sprinkler heads shall be installed under fixed obstructions that are over 4 ft in width.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2010 NFPA 13 8.6.5.3.3

Based on document review and staff interview, the facility failed to test and maintain the fire sprinkler system in accordance with the 2012 NFPA 101, Life Safety Code, and 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to properly test and maintain the fire sprinkler system as required may lead to system failure, which could result in injury or death during an emergency. The deficiencies could impact all patients, staff, and visitors within the facility.

The findings were:

1) Document review on 11/08/2022 starting at 3:20 PM revealed that testing of the priming water and the low air alarm for the fire sprinkler dry system had been tested once in the last twelve months. The priming water and low air alarm shall be tested quarterly.

Interview with facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2011 NFPA 25 13.4.4.2.1, 13.4.4.2.6

2) Document review on 11/08/2022 starting at 3:20 PM revealed no evidence that the full trip test for the fire sprinkler dry system had been tested in the last three (3) years. No documentation was available at the time of the inspection to indicate when the last full trip test of the system had been performed.

Interview with Facilities Director at the time of the observation acknowledge the deficiency, and indicated that they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2011 NFPA 25 13.4.4.2.2.2

3) Document review on 11/08/22 starting at 3:20 PM revealed no evidence that the hydrostatic test or the flow test for the fire sprinkler standpipe had been conducted in the last five (5) years. No documentation was available at the time of the inspection to indicate when the last hydrostatic or flow test had been performed.

Interview with facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2011 NFPA 25 6.3.1, 6.3.2

Based on document review and staff interview, the facility failed to test and maintain the fire sprinkler system in accordance with the 2012 NFPA 101, Life Safety Code, and 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to properly test and maintain the fire sprinkler system could result in a failure of the system as required may lead to system failure, which could result in injury or death during an emergency. The deficiencies could impact all patients, staff, and visitors within the facility.

The findings were:

1) Document review on 11/08/2022 starting at 3:20 PM revealed that testing of the priming water and the low air alarm for the fire sprinkler dry system had been tested once in the last twelve months. The priming water and low air alarm shall be tested quarterly.

Interview with facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2011 NFPA 25 13.4.4.2.1, 13.4.4.2.6

2) Document review on 11/08/2022 starting at 3:20 PM revealed no evidence that the full trip test for the fire sprinkler dry system had been conducted in the last three (3) years. No documentation was available at the time of the inspection to indicate when the last full trip test of the system had been performed.

Interview with facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2011 NFPA 25 13.4.4.2.2.2

Based on observation and staff interview, the facility failed to maintain smoke compartment barriers in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly maintain smoke compartment barriers could result in spread of smoke and fire, which could result in injury or death. The deficiency affected one (1) of five (5) smoke compartment barriers on the 1st floor, and could impact all patients, staff, and visitors in the area.

The findings were:

Observation on 11/08/2022 at 2:59 PM revealed a smoke compartment barrier that runs adjacent to the wound care suite and the OR Suite. Observation above the cross corridor doors adjacent to the ambulance garage revealed multiple unprotected plumbing and electrical conduit penetrations. Smoke compartment barriers shall maintain a 1/2-hour fire resistance rating, and be sealed to limited the transfer of smoke.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.3.7.3

Based on observation and staff interview, the facility failed to protect and maintain elevators and dumbwaiters in accordance with the 2012 NFPA 101, Life Safety Code, and the 2008 ASME A17.3, Safety Code for Existing Elevators and Escalators. Failure to properly protect and maintain elevators and dumbwaiters could result in the spread of smoke and fire, which could result in injury or death. The deficiency affected two (2) dumbwaiters that connected the sterile processing suite and the OR Suite, and could impact all patients, residents, and visitors in those areas.

The findings were:

Observation on 11/07/2022 at 10:08 AM revealed two (2) machine rooms for dumbwaiters located in the sterile processing suite. Observation of the machine rooms for the dumbwaiters revealed that the rooms were being used to store large amounts of combustible materials. Dumbwaiter machine rooms shall only contain equipment that is used in connection with the operation of the dumbwaiter.

Interview with the facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 101 19.5.3, 9.4.2.2; 2008 ASME A17.3 2.2.1

Based on observation and staff interview, the facility failed to utilize power strips in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly utilize power strips could result in Patient Care Related Electrical Equipment (PCREE) working improperly which could result in injury or death in the event of a malfunction. The deficiency affected one (1) of one (1) endoscopy procedure room and could impact any patients or staff in the room.

The findings were:

Observation on 11/07/2022 at 3:04 PM revealed a power strip located on the floor of the endoscopy procedure room located in the OR suite. Power strips shall be permitted to be used as part of a movable equipment assembly provided it is permanently attached to the equipment assembly, the sum of all appliances connected does not exceed 75 percent of the ampacity of the power strip, and means are employed to ensure that additional devices or non-medical equipment cannot be connected.

Interview with facilities director at the time of the observation acknowledge the deficiency, and indicated they were aware of the requirement.

Interview with the CEO at the time of the exit acknowledge the deficiency.

Ref: 2012 NFPA 99 10.2.3.6