HospitalInspections.org

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering.

The findings include:

In the 48 Building on the second floor, the emergency exit door at the Provider Room in the mid-level has a slide lock preventing the door to be used as an exit.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

1. In the Basement ATS Room (EVS Storage) there was no battery operated emergency light in the generator equipment room.

2. In the Hospital Building in the mechanical room in the upstairs loft area that is housing the ATS equipment, there was no battery operated emergency light installed.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors.
The findings include:

1. In the 48 Building on the first floor, the door to the corridor from the storage room labeled "Keep Out" over 50 square feet was not equipped with a self-closing device.

2. In the basement in the Hospital Building, the rated fire door that opens from the electrical room (EVS Supply Storage) was not equipped with a self-closing device.

3. In the 48 Building on the first floor, the rated fire door that opens from the PPE Room was not equipped with a self-closing device.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.
The findings include:

1. The facility was unable to provide documentation showing the Fire Alarm system has been tested and maintained for the semi-annual inspection, testing, and maintenance within the past 12 months.

2. The facility has not maintained a nuisance log, which is required for a zoned fire alarm system, to allow sensitivity testing to be completed on five-year intervals. Sensitivity testing documentation states last testing was completed on 12-06-2021. Facility shall complete smoke detector sensitivity testing.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the hospital.

The findings include:

1. The facility could not provide documentation indicating their automatic sprinkler system has received the annual forward flow test within the last twelve months for the 48 Building.

2. In the Hospital Building there were sprinkler heads in the basement electrical room that were obstructed by combustible material stored within 18 inches from the bottom of the sprinkler heads.

3. In the 48 Building on the first floor, in the utility room there was an escutcheon cap that was sliding off the fire sprinkler piping.

4. In the 48 Building on the first floor, in the fire riser room there was a broken escutcheon cap near the riser.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the hospital.
The findings include:

1. In the 48 Building on the first floor, in the Kitchen the portable fire extinguisher was blocked by a garbage bin.
2. In the 48 Building on the first floor, in the generator room there were two unsecured fire extinguishers located on the shelves.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

1. In the 48 Building on the first floor, the door to the Pharmaceutical waste room did not fully close and latch.

2. In the 48 Building on the first floor, the fire door to the ER Intake desk there was a payment device cord that was blocking the fire drop door preventing it from fully closing and latching.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to properly maintain fire/smoke barriers doors within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

1. In the 48 Building on the first floor, the Nurses breaker has a small penetration behind the fridge.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility has failed to properly maintain fire/smoke barriers doors within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

In the 48 Building on the first floor, the rated fire door that opens from the Generator Room failed to fully close and latch when tested.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730-1100 hours, the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.
The findings include:

In the 48 Building on the second floor, in the corridor near the Women's Sleep room there was a broken and missing electrical outlet cover.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the hospital has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.
The findings include:

The facility failed to note in several of the fire drill records the type of initiation device and location of the simulated emergency.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the hospital has failed to prohibit the use of all space heaters in resident areas and non-approved heaters in staff areas. This could result in a fire due to the ignition of combustible materials that would place patients, staff, and/or visitors in danger.

The findings include:

1. In the 48 Building on the second floor, there was a portable heater in the Credentialing Office with no automatic shut-off switch when tipped over.
2. In the 48 Building on the first floor, there was a portable heater in the Supply Storage with combustible storage within 3 feet of the heating element.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected, and thus place patients, staff, and visitors to the threat of an accelerated fire.

The findings include:

The facility could not provide documentation showing periodic testing of the medical gas equipment.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/05/2025 between approximately 1145 to 1630 hours, and 02/06/2025 between approximately 0730 to 1100 hours, the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

1. In the 48 Building on the first floor in the Maintenance Office there was an extension cord plugged into a power strip used in place of permanent wiring under the desk.

2. In the 48 Building on the first floor in the Maintenance Office there was an unfused multiplug adapter in use.

3. In the 48 Building on the first floor in the Maintenance Office there was a power strip (desk unit) with two power strips daisy-chained and in use.

4. In the Hospital Building on the first floor in the Kitchen Office there was an unfused power strip plugged into an unfused power strip.

5. In the Hospital Building on the first floor in the IT Office (Room 16) there was a power strip plugged into a power strip.

6. In the Hospital Building on the first floor in the Lab there was a fridge used for patient care plugged into a medical grade power strip, and not into a direct outlet.

The above was discussed and acknowledged by the facility staff.