HospitalInspections.org

Based upon observation, the hospital failed to maintain doors protecting corridor openings in other than required enclosures of vertical opening, exits, or hazardous areas in such condition that they will close without impediments and that the door latches.

Failure to maintain doors protecting corridor openings risks inability to contain a fire to a room and prevent the movement of the toxic products of combustion to enter patient rooms.

Findings include but are not limited to:

During a tour of the hospital on 12/13/2011, it was observed that the following rooms had doors protecting corridor openings, with automatic closures. These doors were all held open by floor wedges and were unattended:

Rooms 410, 411 and 412.

The hospital facilities manager confirmed the observations.

Based on observation, the hospital failed to mark exits clearly where the way to reach an exit was not readily apparent.

Failure to clearly mark exits risks confusion in the event of an emergency requiring evacuation.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that the 1st floor east-west corridor that runs adjacent to the hospital lobby had a point midway down the west branch of the corridor where the route of exit was not clearly marked. An exit could be seen at the west end of the corridor, but the alternate route of egress that led toward the laboratory in a north-south corridor was not marked.

The hospital facilities manager confirmed the observation.

Based upon observation, the facility failed to maintain the construction of a smoke barrier wall so as to provide at least a one-hour fire resistive rated construction.

Failure to maintain a smoke barrier wall risks passage of smoke from one smoke
compartment to another and could expose all patients in both compartments to toxic products of combustion.

Findings include but are not limited to:

During a tour of the hospital on 12/13/2011, it was observed that smoke barrier walls had unsealed penetrations in multiple locations in the hospital, including:

The ICU smoke barrier wall over the staff workroom
The 2nd floor above the smoke barrier doors on the east side of the dual-elevator bank
The joint where the smoke barrier wall meets the next higher floor deck above the locker rooms on the 2nd floor

The hospital facilities manager confirmed the observations.

Based upon observation, the hospital failed to maintain smoke barrier doors so that they will self-close and resist the passage of smoke.

Failure to maintain smoke barrier doors as required risks exposure of patients in both smoke compartments to the toxic products of combustion and smoke.

Findings include but are not limited to:

During a tour of the hospital on 12/14/2011, the deputy state fire marshal observed by his report to Surveyor #1 that the elevator lobby doors on the 1st floor of the hospital failed to fully close when released.

Based upon observation, the hospital failed to maintain hazardous areas so that they are separated from other spaces by smoke resisting partitions and doors.

Failure to maintain hazard area separation risks passage of toxic products of combustion and smoke to beyond the hazardous area and into the patient care
areas.

Findings include but are not limited to:

During a tour of the critical access hospital on 12/13/2011, it was observed that patient room 3110 had been converted to storage, and contained a high volume of combustible items, including 5 upholstered chairs, 1 child's bed, 1 adults bed, various plastic bins and other combustible items.

The hospital facilities manager confirmed the observation.

Based upon interview the hospital failed to successfully implement its written procedure for fire and evacuation.

Failure to establish and train to an appropriate written fire and evacuation plan risks failure of hospital personnel to respond quickly to an emergency.

Findings include:

During a tour of the hospital on 12/13/2011, nursing managers in the intensive care unit and OB/post-partum unit were asked what they would do with their patients if their units were filled with smoke and they felt they had to leave the unit. Both managers stated that they would evacuate patients to the out of doors. Neither manager referred to smoke compartmentation, and when asked whether there were areas on the same floor that they could evacuate their patients into, they responded with uncertainty.

The hospital facilities manager confirmed that the hospital fire plan is to evacuate between smoke compartments on the same hospital floor when possible.

Based on observation the hospital failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

During a tour of the hospital on 12/14/2011, the deputy state fire marshal observed by his report to Surveyor #1 that portable space heating devices that did not meet the requirements of the Code were located in the radiology assistant's office and in the mammography suite.

Based upon observation, the hospital failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in rooms protected as hazardous areas.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include:

During a tour of the hospital on 12/14/2011, the deputy state fire marshal observed by his report to Surveyor #1 that the radiology file room contained two wheeled containers exceeding 32 gallons in size, and one garbage can that contained radiology film. The room was not protected as a hazardous area.

Based on observation and interview, the hospital failed to protect medical gas storage areas in accordance with NFPA 99.

Failure to maintain required separation of oxygen storage and distribution areas risks venting or leakage of oxygen into areas that present a fire hazard, potentially leading to the rapid spread of fire and smoke.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that a penetration had been made into the one-hour rated separation around the reserve oxygen storage and distribution room. The penetration opened into an adjacent area of the hospital according to the hospital facilities manager.

Based upon observation, the facility failed to maintain the relative humidity equal to or greater than 35% in anesthetizing locations.

Humidity levels below 35% are conducive to the production of static electrical discharges that could ignite a fire and endanger patients and staff in these locations.

Findings include but are not limited to:

During a tour of the hospital on 12/14/2011 at approximately 1:15 p.m., it was observed that humidity monitors attached to the walls of the hospital operating rooms 1, 3, 4 and 5 showed humidity readings of between 16% and 20%.


During a return to the surgery department on 12/15/2011 at approximately 10:20 a.m. the humidity readings in three of the five operating rooms were:

Operating room #1 24.6%
Operating room #4 23.0%
Operating room #5 21.4%

In an interview on 12/16/2011, hospital facilities manager stated that the hospital does have the ability to adjust humidity levels in the operating rooms, but the equipment was malfunctioning. He also stated that it was the hospital's belief that the correct minimum level of humidity was 20%.

TAG K037 2000 EXISTING

Existing dead-end corridors shall be permitted to be continued to be used if it is impractical and unfeasible to alter them so that exits are accessible in not less than two different directions from all points in aisles, passageways, and corridors. 19.2.5.10

This requirement is not met as evidenced by:

Based on observation, the hospital failed to prevent the creation of a dead-end corridor.

Dead-end corridors risk entrapment during a fire or other emergency.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that a corridor had been constructed on the 2nd floor (west end of the hospital) where a large warehouse space existed. The corridor contained locker rooms and a physician sleep room. The corridor had only one exit at the east end that led into a hospital egress path. The west end of the corridor led into the warehouse space.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that conduit penetrating smoke barrier walls was not sealed in several locations, including the OB/post-partum electrical closet and above the smoke barrier doors at the east end of the 2nd floor locker room corridor.

The hospital facilities manager confirmed the observations.

Based upon observation, the hospital failed to maintain doors protecting corridor openings in other than required enclosures of vertical opening, exits, or hazardous areas in such condition that they will close without impediments and that the door latches.

Failure to maintain doors protecting corridor openings risks inability to contain a fire to a room and prevent the movement of the toxic products of combustion to enter patient rooms.

Findings include but are not limited to:

During a tour of the hospital on 12/13/2011, it was observed that the following rooms had doors protecting corridor openings, with automatic closures. These doors were all held open by floor wedges and were unattended:

Rooms 410, 411 and 412.

The hospital facilities manager confirmed the observations.

Based on observation, the hospital failed to mark exits clearly where the way to reach an exit was not readily apparent.

Failure to clearly mark exits risks confusion in the event of an emergency requiring evacuation.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that the 1st floor east-west corridor that runs adjacent to the hospital lobby had a point midway down the west branch of the corridor where the route of exit was not clearly marked. An exit could be seen at the west end of the corridor, but the alternate route of egress that led toward the laboratory in a north-south corridor was not marked.

The hospital facilities manager confirmed the observation.

Based upon observation, the facility failed to maintain the construction of a smoke barrier wall so as to provide at least a one-hour fire resistive rated construction.

Failure to maintain a smoke barrier wall risks passage of smoke from one smoke
compartment to another and could expose all patients in both compartments to toxic products of combustion.

Findings include but are not limited to:

During a tour of the hospital on 12/13/2011, it was observed that smoke barrier walls had unsealed penetrations in multiple locations in the hospital, including:

The ICU smoke barrier wall over the staff workroom
The 2nd floor above the smoke barrier doors on the east side of the dual-elevator bank
The joint where the smoke barrier wall meets the next higher floor deck above the locker rooms on the 2nd floor

The hospital facilities manager confirmed the observations.

Based upon observation, the hospital failed to maintain smoke barrier doors so that they will self-close and resist the passage of smoke.

Failure to maintain smoke barrier doors as required risks exposure of patients in both smoke compartments to the toxic products of combustion and smoke.

Findings include but are not limited to:

During a tour of the hospital on 12/14/2011, the deputy state fire marshal observed by his report to Surveyor #1 that the elevator lobby doors on the 1st floor of the hospital failed to fully close when released.

Based upon observation, the hospital failed to maintain hazardous areas so that they are separated from other spaces by smoke resisting partitions and doors.

Failure to maintain hazard area separation risks passage of toxic products of combustion and smoke to beyond the hazardous area and into the patient care
areas.

Findings include but are not limited to:

During a tour of the critical access hospital on 12/13/2011, it was observed that patient room 3110 had been converted to storage, and contained a high volume of combustible items, including 5 upholstered chairs, 1 child's bed, 1 adults bed, various plastic bins and other combustible items.

The hospital facilities manager confirmed the observation.

Based upon interview the hospital failed to successfully implement its written procedure for fire and evacuation.

Failure to establish and train to an appropriate written fire and evacuation plan risks failure of hospital personnel to respond quickly to an emergency.

Findings include:

During a tour of the hospital on 12/13/2011, nursing managers in the intensive care unit and OB/post-partum unit were asked what they would do with their patients if their units were filled with smoke and they felt they had to leave the unit. Both managers stated that they would evacuate patients to the out of doors. Neither manager referred to smoke compartmentation, and when asked whether there were areas on the same floor that they could evacuate their patients into, they responded with uncertainty.

The hospital facilities manager confirmed that the hospital fire plan is to evacuate between smoke compartments on the same hospital floor when possible.

Based on observation the hospital failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

During a tour of the hospital on 12/14/2011, the deputy state fire marshal observed by his report to Surveyor #1 that portable space heating devices that did not meet the requirements of the Code were located in the radiology assistant's office and in the mammography suite.

Based upon observation, the hospital failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in rooms protected as hazardous areas.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include:

During a tour of the hospital on 12/14/2011, the deputy state fire marshal observed by his report to Surveyor #1 that the radiology file room contained two wheeled containers exceeding 32 gallons in size, and one garbage can that contained radiology film. The room was not protected as a hazardous area.

Based on observation and interview, the hospital failed to protect medical gas storage areas in accordance with NFPA 99.

Failure to maintain required separation of oxygen storage and distribution areas risks venting or leakage of oxygen into areas that present a fire hazard, potentially leading to the rapid spread of fire and smoke.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that a penetration had been made into the one-hour rated separation around the reserve oxygen storage and distribution room. The penetration opened into an adjacent area of the hospital according to the hospital facilities manager.

Based upon observation, the facility failed to maintain the relative humidity equal to or greater than 35% in anesthetizing locations.

Humidity levels below 35% are conducive to the production of static electrical discharges that could ignite a fire and endanger patients and staff in these locations.

Findings include but are not limited to:

During a tour of the hospital on 12/14/2011 at approximately 1:15 p.m., it was observed that humidity monitors attached to the walls of the hospital operating rooms 1, 3, 4 and 5 showed humidity readings of between 16% and 20%.


During a return to the surgery department on 12/15/2011 at approximately 10:20 a.m. the humidity readings in three of the five operating rooms were:

Operating room #1 24.6%
Operating room #4 23.0%
Operating room #5 21.4%

In an interview on 12/16/2011, hospital facilities manager stated that the hospital does have the ability to adjust humidity levels in the operating rooms, but the equipment was malfunctioning. He also stated that it was the hospital's belief that the correct minimum level of humidity was 20%.

TAG K037 2000 EXISTING

Existing dead-end corridors shall be permitted to be continued to be used if it is impractical and unfeasible to alter them so that exits are accessible in not less than two different directions from all points in aisles, passageways, and corridors. 19.2.5.10

This requirement is not met as evidenced by:

Based on observation, the hospital failed to prevent the creation of a dead-end corridor.

Dead-end corridors risk entrapment during a fire or other emergency.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that a corridor had been constructed on the 2nd floor (west end of the hospital) where a large warehouse space existed. The corridor contained locker rooms and a physician sleep room. The corridor had only one exit at the east end that led into a hospital egress path. The west end of the corridor led into the warehouse space.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

During a tour of the hospital on 12/13/2011, it was observed that conduit penetrating smoke barrier walls was not sealed in several locations, including the OB/post-partum electrical closet and above the smoke barrier doors at the east end of the 2nd floor locker room corridor.

The hospital facilities manager confirmed the observations.